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    v1.0.28
    OpenPayerPolicy UpdatesGastroenterologyColorado Rocky Mountain GI Policy Update | OpenPay…
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    CurrentColorado Rocky Mountain Health PlansPolicy MMP039.20

    Gastroesophageal and Gastrointestinal (GI) Services and Procedures

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    This Medicare Advantage medical policy addresses coverage guidance and applicable Medicare coverage resources for selected gastroesophageal and gastrointestinal diagnostic procedures, neurostimulation therapies, and endoscopic myotomy procedures. It directs providers to applicable Medicare LCDs/LCAs or related commercial policies when Medicare has not established coverage criteria.

    Policy Summary
    PayerColorado Rocky Mountain Health Plans
    PolicyGastroesophageal and Gastrointestinal (GI) Services and Procedures
    Policy CodePolicy MMP039.20
    Change TypeMaterial revision
    Effective DateOct 1, 2026
    Next Review DateN/A
    Key ActionFor POEM procedures, comply with applicable Medicare LCDs or LCAs; where none exist, use the referenced commercial policy guidelines.
    SourceLink
    POLICY UPDATE CHANGES

    Coverage rationale language addressing virtual upper gastrointestinal endoscopy was removed.

    CPT codes 76497 and 76498 were removed from the applicable codes section.

    The list of documents available in the Medicare Coverage Database was updated to reflect current information.

    The previous policy version MMP039.19 was archived as part of the revision.

    5

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    Procedure and therapy categories addressed
    2Procedures identified as non-covered
    3CMS coverage documents listed
    4Policy pages

    Coverage Criteria

    Electrogastrography, diagnostic, transcutaneous with provocative testing is identified as non-covered under this policy.

    Applicable Codes and Related Documents

    Electrogastrography or Electroenterography — Coverage Not SpecifiedCPT
    91132Electrogastrography or Electroenterography; electrogastrography, diagnostic, transcutaneous.
    Electrogastrography or Electroenterography — Not-Covered CPT CodesCPTNot Covered
    91133Electrogastrography, diagnostic, transcutaneous; with provocative testing (Non-Covered).
    Esophageal Mucosal Integrity TestingCPT
    43499Unlisted Procedure, Esophagus.
    Gastric Electrical Stimulation TherapyCPT
    43647Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum.
    43648Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum.
    43881Implantation or replacement of gastric neurostimulator electrodes, antrum, open.
    43882Revision or removal of gastric neurostimulator electrodes, antrum, open.
    Gastric Per Oral Endoscopic Myotomy (G-POEM)CPT
    43499Unlisted procedure, esophagus.
    43999Unlisted procedure, stomach.
    Per Oral Endoscopic Myotomy (POEM)CPT
    43497Lower esophageal myotomy, transoral (i.e., peroral endoscopic myotomy [POEM]).
    43499Unlisted procedure, esophagus.
    43999Unlisted procedure, stomach.
    CMS Related Documentsmixed
    L38747Peroral Endoscopic Myotomy (POEM).
    A58287Billing and Coding: Peroral Endoscopic Myotomy.

    Provider Responsibilities

    Prior Authorization

    Check the applicable POEM LCD or LCA

    For POEM procedures in jurisdictions with applicable LCDs or LCAs, compliance with those policies is required. Where no LCD or LCA exists, refer to the UnitedHealthcare Commercial Medical Policy titled “Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases.”

    Prior Authorization

    Follow delegate authorization requirements

    When a delegate manages utilization management and prior authorization requirements for a member’s Medicare Advantage plan, providers must follow the delegate’s requirements.

    Documentation Required

    Retain supporting documentation

    Policy Scope and Background

    This policy addresses selected gastrointestinal diagnostic and therapeutic services, including electrogastrography and esophageal mucosal integrity testing, gastric electrical stimulation therapy, and endoscopic myotomy procedures such as G-POEM and POEM. Applicable coding and coverage guidance varies by service and procedure.

    Policy Summary
    PayerColorado Rocky Mountain Health Plans
    PolicyGastroesophageal and Gastrointestinal (GI) Services and Procedures
    Policy CodePolicy MMP039.20
    Change TypeMaterial revision
    Effective DateOct 1, 2026
    Next Review DateN/A
    Key ActionFor POEM procedures, comply with applicable Medicare LCDs or LCAs; where none exist, use the referenced commercial policy guidelines.
    SourceLink
    On This Page
    Coverage CriteriaApplicable Codes and Related DocumentsProvider ResponsibilitiesPolicy Scope and Background

    Retain or have access to appropriate documentation when requested to support coverage, including medical necessity, documentation, and Medicare coding or billing requirements.

    Billing Rule

    Submit accurate claims

    Submit accurate claims and follow applicable CPT, CMS, and other coding guidelines. These references define coding requirements but do not imply a right to reimbursement or guarantee claims payment.

    Denial Risk

    Avoid non-covered electrogastrography with provocative testing

    Electrogastrography, diagnostic, transcutaneous with provocative testing is identified as non-covered. Claims for CPT 91133 may therefore be denied as non-covered.

    • CPT 91133: Electrogastrography, diagnostic, transcutaneous; with provocative testing (Non-Covered).
    Denial Risk

    Follow applicable POEM coverage guidance

    For per oral endoscopic myotomy, comply with applicable Medicare LCDs or LCAs where they exist. For states or territories without an LCD or LCA, use the referenced UnitedHealthcare Commercial Medical Policy titled “Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases.”

    • Applicable POEM codes include 43497, 43499, and 43999.