CurrentAmeriHealth CaritasPolicy CCP.1357

Gastroparesis Evaluations

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Defines medical necessity criteria and coverage stance for diagnostic testing to document delayed gastric emptying (scintigraphy, carbon-13 breath test, wireless motility capsule) for members with suspected gastroparesis and who have been evaluated by a gastroenterologist.

Policy Summary

PayerAmeriHealth Caritas

PolicyGastroparesis Evaluations

Policy CodePolicy CCP.1357

Change TypeNo material changes

Effective DateFeb 1, 2024

Last ReviewFeb 1, 2026

Next Review DateJun 1, 2027

Key ActionObtain documentation of symptoms, exclude mechanical gastric outlet obstruction, and confirm delayed gastric emptying by scintigraphy (or approved alternative) with interpretation by a gastroenterologist before authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4-hr preferredScintigraphy duration

Adults onlyWMC use

ListedContraindications

MultipleGuideline sources

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CurrentAmeriHealth CaritasPolicy CCP.1357

Gastroparesis Evaluations

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Sign up for AmeriHealth Caritas Policy CCP.1357 alerts

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Policy Summary

PayerAmeriHealth Caritas

PolicyGastroparesis Evaluations

Policy CodePolicy CCP.1357

Change TypeNo material changes

Effective DateFeb 1, 2024

Last ReviewFeb 1, 2026

Next Review DateJun 1, 2027

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4-hr preferredScintigraphy duration

Adults onlyWMC use

ListedContraindications

MultipleGuideline sources

Coverage and Medical Necessity Criteria

Medically necessary diagnostic testing for gastroparesis

Covered when ALL of the following are met

Primary criteria: Presence of symptoms of suspected gastroparesis (e.g., nausea, vomiting, early satiety, postprandial fullness, bloating, upper abdominal pain)

Exclude obstruction: Absence of demonstrable mechanical obstruction of the gastric outlet (e.g., by endoscopy or contrast study)

Basic investigations: Non-diagnostic basic clinical investigations, including upper endoscopy

Documentation of delayed gastric emptying: Delayed gastric emptying must be documented by either gastric emptying scintigraphy of a radiolabeled solid meal OR, if scintigraphy is contraindicated or not feasible, a wireless gastrointestinal motility monitoring capsule OR a stable-isotope (carbon-13) breath test

Wireless motility capsule limited to adults and contraindications apply

Specialist evaluation: Evaluation by a gastroenterologist trained to use and interpret the results

All other modalities used to verify delayed gastric emptying in the absence of demonstrable mechanical gastric outlet obstruction are considered investigational/not clinically proven and therefore not medically necessary. Examples include radiopaque marker testing, MRI-based studies, HIDA scan, and electrogastrography when used as substitutes for standard diagnostic methods.

The wireless motility capsule is considered investigational/not clinically proven and not medically necessary in pediatric members, as it is not approved for use in the pediatric population by the U.S. Food and Drug Administration.

Use of the wireless motility capsule in pediatric members and other non‑standard modalities to verify delayed gastric emptying are not medically necessary due to lack of demonstrated clinical validity and regulatory approval for pediatrics.

Codes and Test Parameters

Related/commonly submitted codesmixed

78264	Gastric emptying imaging study (e.g., solid, liquid, or both);
78265	Gastric emptying imaging study (e.g., solid, liquid, or both); with small bowel transit.
78266	Gastric emptying imaging study (e.g., solid, liquid, or both); with small bowel and colon transit, multiple.
91020	Gastric motility (manometric) studies.
91022	Duodenal motility (manometric) study.
91112	Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report.
0106U	Gastric emptying, serial collection of 7 timed breath specimens, non-radioisotope carbon-13 (13C) spirulina substrate, analysis of each specimen by gas isotope ratio mass spectrometry, reported as rate of 13CO2 excretion

Scintigraphy duration — preference and rationale

Preferred scintigraphy durationFour-hour gastric emptying scintigraphy is preferred over two-hour studies (4-hour threshold recommended)

Minimum reliable measurementScintigraphy is most reliable when measuring emptying of a solid meal over at least three hours

Guideline rationaleFour-hour studies have superior diagnostic accuracy compared with two-hour studies

Provider Requirements, Documentation, and Billing

Billing Rule

Billing/prior authorization — use listed codes and follow payer rules

Consult payer prior authorization rules before billing for diagnostic tests. Relevant CPT/HCPCS codes commonly submitted for these services include gastric emptying scintigraphy (78264, 78265, 78266), gastric/duodenal manometry (91020, 91022), wireless motility capsule (91112), and carbon‑13 breath test (0106U). Providers must use the payer's prior authorization process and code-specific rules when requesting coverage.

78264, 78265, 78266 — gastric emptying scintigraphy
91020, 91022 — manometry studies
91112 — wireless motility capsule
0106U — carbon‑13 (13C) breath test

Step Therapy

Initial clinical evaluation required before diagnostic testing

Clinical Background

Gastroparesis is a disorder of gastric motility characterized by prolonged gastric emptying in the absence of a mechanical gastric outlet obstruction. Clinically, patients commonly present with nausea, vomiting, early satiety, postprandial fullness, bloating, weight loss, and upper abdominal pain. Diagnosis requires documentation of delayed gastric emptying and exclusion of a mechanical obstruction.

Definitions and Test Descriptions

Gastroparesis definition

Definition of gastroparesisDelayed gastric emptying of fluids and/or solids without evidence of mechanical gastric outlet obstruction, lasting at least three months

Common presenting symptomsNausea, vomiting, early satiety, postprandial fullness, bloating, weight loss, and upper abdominal pain

Diagnostic requirementsDiagnosis requires documentation of delayed gastric emptying and exclusion of mechanical obstruction (e.g., endoscopy or contrast study)

Gastric emptying scintigraphy — test description and standards

Test descriptionGastric emptying scintigraphy is a radiolabeled solid‑meal imaging test considered the standard, noninvasive, quantifiable measure of gastric emptying

Preferred measurement duration

Policy Summary

PayerAmeriHealth Caritas

PolicyGastroparesis Evaluations

Policy CodePolicy CCP.1357

Change TypeNo material changes

Effective DateFeb 1, 2024

Last ReviewFeb 1, 2026

Next Review DateJun 1, 2027

SourceLink

On This Page

Perform a routine clinical evaluation and management visit by a network health care provider before ordering diagnostic testing; diagnostic studies should follow an initial clinical assessment that documents symptoms and the need for testing.

Routine patient evaluation and management by a network health care provider is an alternative covered service
Diagnostic testing should follow initial clinical evaluation documenting symptoms consistent with suspected gastroparesis

Documentation Required

Required documentation to support testing

Include documentation demonstrating symptoms of suspected gastroparesis, exclusion of mechanical gastric outlet obstruction (e.g., upper endoscopy or contrast study), nondiagnostic basic investigations, and evaluation by a gastroenterologist trained to use and interpret the chosen test.

Symptoms: nausea, vomiting, early satiety, postprandial fullness, bloating, upper abdominal pain
Exclude mechanical obstruction with endoscopy or contrast study
Record nondiagnostic results of basic clinical investigations (including upper endoscopy)
Document that a gastroenterologist trained to interpret the selected test evaluated the member

Denial Risk

Denial triggers — investigational modalities and WMC limitations/contraindications

Requests for diagnostic modalities not listed as clinically proven may be denied; wireless motility capsule may also be denied when contraindications or pediatric use apply.

Modalities other than gastric emptying scintigraphy, carbon‑13 breath testing, or wireless motility capsule (where allowed) are considered investigational and not medically necessary
Wireless motility capsule is investigational and not medically necessary in pediatric members
Wireless motility capsule contraindications that can trigger denial include history of gastric bezoar, swallowing disorders/dysphagia, suspected strictures/fistulae, recent GI surgery (within 3 months), Crohn's disease, diverticulitis, or implanted electromechanical devices

Preferably measured over at least four hours (four-hour study recommended over two-hour due to better diagnostic accuracy)

Alternatives and limitationsCarbon-13 breath testing and wireless motility capsule are alternatives but have limitations due to lack of standardization and availability