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    v1.0.31
    OpenPayerPolicy UpdatesGastroenterologyAmeriHealth VIP Alimetry Policy Update | OpenPayer
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    CurrentAmeriHealth Caritas VIP CarePolicy CCP.1565

    Pediatric Gastric Alimetry

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    This policy governs coverage of gastric alimetry and body surface gastric mapping used to evaluate pediatric gastroduodenal symptoms, including suspected gastroparesis, chronic nausea and vomiting, and gastric dysmotility. These services are considered investigational, not clinically proven, and not medically necessary for pediatric populations.

    Policy Summary
    PayerAmeriHealth Caritas VIP Care
    PolicyPediatric Gastric Alimetry
    Policy CodePolicy CCP.1565
    Change TypeNo material change
    Effective DateAugust 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateOctober 1, 2027
    Key ActionDo not expect coverage for pediatric gastric alimetry or body surface gastric mapping because the services are considered investigational and not medically necessary.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Not coveredPediatric coverage stance
    0868TCommonly submitted code
    64Mapping electrodes
    56Symptomatic adolescent study

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    123Adolescent normative study
    NoneAlternative covered services

    Pediatric Gastric Alimetry and Body Surface Gastric Mapping

    Pediatric gastric alimetry and body surface gastric mapping

    Not medically necessary.

    Pediatric gastric alimetry or body surface gastric mapping: Gastric alimetry and body surface gastric mapping performed for a pediatric patient are considered investigational/not clinically proven and therefore not medically necessary.

    The policy does not establish a covered pediatric indication or exception.

    For pediatric patients, gastric alimetry and body surface gastric mapping are considered investigational, not clinically proven, and not medically necessary. The policy does not establish a covered pediatric indication or exception for these services.

    Coding and Reference Measures

    Investigational / Not Medically NecessaryCPTExperimental
    0868Tgastric alimetry and body surface gastric mapping
    Principal gastric frequency
    Reference interval2.65 to 3.35 cycles per minute
    PopulationAdults
    MeasureDominant rhythm of gastric slow-wave activity
    Gastric alimetry rhythm index
    Reference value0.25 or greater
    PopulationAdults
    MeasureRhythm stability
    Body mass index-adjusted amplitude
    Reference interval20 to 70 microvolts
    PopulationAdults
    MeasureStrength of the gastric electrical signal
    Fed-to-fasted amplitude ratio
    Reference value1.08 or greater
    PopulationAdults
    MeasureMeal response of the stomach
    Adolescent principal gastric frequency
    Reference interval2.72 to 3.37 cycles per minute
    PopulationAdolescents ages 12 to 17 years
    Study basisEstablished in a multicenter healthy-adolescent normative study
    Adolescent body mass index-adjusted amplitude
    Reference interval20.0 to 72.0 microvolts
    PopulationAdolescents ages 12 to 17 years
    Study basisEstablished in a multicenter healthy-adolescent normative study
    Adolescent gastric rhythm index
    Reference valueAt least 0.22
    PopulationAdolescents ages 12 to 17 years
    MeasureGastric rhythm index
    Adolescent fed-to-fasted amplitude ratio
    Reference valueAt least 1.0
    PopulationAdolescents ages 12 to 17 years
    MeasureFed-to-fasted amplitude ratio

    Provider and Coverage Implications

    Denial Risk

    Pediatric use is not covered

    Coverage may be denied because gastric alimetry and body surface gastric mapping for pediatric populations are considered investigational, not clinically proven, and therefore not medically necessary. This applies even when proposed for refractory gastroparesis, chronic nausea and vomiting syndrome, or suspected gastric dysmotility after failed initial medical management.

    Clinical Background

    Gastric alimetry, also called body surface gastric mapping, is a noninvasive test that records gastric myoelectrical activity from the abdominal skin surface while symptoms are logged. Pediatric chronic gastroduodenal symptoms may include nausea, vomiting, early satiety, postprandial fullness, and epigastric pain, with overlap among gastroparesis, functional dyspepsia, and chronic nausea and vomiting syndromes. Available pediatric evidence provides preliminary clinical validity and adolescent reference intervals but has not demonstrated that mapping-guided management improves symptoms, quality of life, school attendance, health care utilization, or avoidance of invasive testing. Guideline-supported evaluation of suspected gastroparesis remains centered on direct gastric emptying measurement.

    Definitions

    Gastric alimetry
    DefinitionA noninvasive test that records gastric myoelectrical activity from the abdominal skin surface while symptoms are logged during testing.
    System components64 electrodes arranged in an 8-by-8 grid, a wearable signal reader, and a symptom-logging application.
    Typical adult protocolA 30-minute fasting baseline, a standardized 482-kilocalorie meal, and a 4-hour postprandial recording period.
    Body surface gastric mapping
    DefinitionHigh-resolution spatial mapping and spectral analysis of gastric myoelectrical activity obtained from the body surface.
    PurposeCharacterizes gastric rhythm, amplitude, and meal response.
    Policy Summary
    PayerAmeriHealth Caritas VIP Care
    PolicyPediatric Gastric Alimetry
    Policy CodePolicy CCP.1565
    Change TypeNo material change
    Effective DateAugust 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateOctober 1, 2027
    Key ActionDo not expect coverage for pediatric gastric alimetry or body surface gastric mapping because the services are considered investigational and not medically necessary.
    SourceLink
    On This Page
    Pediatric Gastric Alimetry and Body Surface Gastric MappingCoding and Reference MeasuresProvider and Coverage ImplicationsClinical BackgroundDefinitions
    MethodPerformed with gastric alimetry using recordings from the abdominal skin surface.