Prior Authorization Expectation

Prior authorization is expected for requests to perform wireless motility capsule (WMC) testing (CPT 91112). WMC is designated not medically necessary for the evaluation of suspected gastric and intestinal motility disorders and other indications per policy. Prior authorization requests for CPT 91112 will generally be denied in the absence of clearly documented, exceptional clinical circumstances supporting medical necessity.

• Affected code: CPT 91112

Coding and Clinical Documentation

If performed and billed, use CPT 91112 (Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule) with an appropriate interpretation and formal report documented in the medical record. Clinical documentation should include indication for testing, prior diagnostic testing and results, relevant symptoms and duration, contraindications considered (e.g., strictures, altered anatomy, severe pyloric stenosis), medication management (e.g., PPI/H2 blockers held if applicable), and any factors that would justify use despite the policy designation.

• Billing code: CPT 91112 — include interpretation and report
• Document: indication, prior tests/results, symptoms/duration, medication holding, contraindication assessment, rationale if seeking exception

Preferred / Established Alternatives

Preferred and established alternative tests should be considered prior to ordering WMC. Scintigraphic gastric emptying of solids remains the standard for evaluation of gastric emptying and diagnosis of gastroparesis. Other alternative approaches include 13C-spirulina breath testing and radiopaque marker testing for colonic transit, as well as conventional transit studies.

• Preferred alternative: Scintigraphic gastric emptying of solids (standard test)
• Other alternatives: 13C-spirulina breath test; radiopaque marker testing; conventional transit studies