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    v1.0.28
    OpenPayerPolicy UpdatesGastroenterologySelect Health gastroparesis coverage & prior auth …
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    Currentselect_healthPolicy CCP.1357

    Gastroparesis Evaluations

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    Defines medical necessity criteria, limitations, and alternative diagnostic options for evaluating suspected gastroparesis for Select Health members; affects providers ordering gastric emptying diagnostic tests.

    Policy Summary
    Payerselect_health
    PolicyGastroparesis Evaluations
    Policy CodePolicy CCP.1357
    Change TypeNo material changes
    Effective DateMar 1, 2022
    Last ReviewFeb 1, 2026
    Next Review DateJun 1, 2027
    Key ActionDocument gastroparesis symptoms, exclude mechanical gastric outlet obstruction (e.g., endoscopy), complete non-diagnostic basic investigations, and obtain gastroparesis testing results interpreted by a trained gastroenterologist.
    SourceLink
    4-hourrecommended gastric emptying scintigraphy duration
    Investigationalnonstandard tests stance
    Pediatric restrictionpediatric restriction for wireless motility capsule
    Examples listedrelated billing codes

    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.

    Coverage Criteria for Gastroparesis Evaluation

    Medically necessary criteria for gastroparesis evaluation

    Covered when ALL of the following are met:

    Entry 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

    Mechanical obstruction should be excluded by appropriate studies such as endoscopy or barium contrast

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

    Basic investigations must be non-diagnostic prior to physiologic testing

    Documentation of delayed gastric emptying: Delayed gastric emptying documented by either gastric emptying scintigraphy of a radiolabeled solid meal OR, if scintigraphy contraindicated/not feasible, a wireless gastrointestinal motility monitoring capsule OR stable isotope (C13) breath test

    Scintigraphy is standard; alternatives when contraindicated or not feasible

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

    All other modalities for verifying delayed gastric emptying, when there is no demonstrable mechanical obstruction of the gastric outlet, are considered investigational and not medically necessary. Scintigraphy, wireless motility capsule (when appropriate), and stable isotope (C13) breath testing are the accepted methods referenced elsewhere in this policy; alternative or nonstandard physiological tests are not supported by the evidence and therefore are excluded from coverage.

    The wireless motility capsule is contraindicated in members with a history of gastric bezoar, swallowing disorders or dysphagia, suspected strictures or fistulae of the gastrointestinal tract, physiologic gastrointestinal obstruction, recent gastrointestinal surgery within the previous 3 months, Crohn’s disease, diverticulitis, or in those with an implanted electromechanical medical device (for example, a pacemaker or infusion pump).

    The wireless motility capsule is considered investigational and not medically necessary for pediatric members because it is not approved for use in this population by the U.S. Food and Drug Administration.

    Coding and Test Parameters

    Related Codesmixed
    78264Gastric emptying imaging study (e.g., solid, liquid, or both);
    78265Gastric emptying imaging study (e.g., solid, liquid, or both); with small bowel transit.
    78266Gastric emptying imaging study (e.g., solid, liquid, or both); with small bowel and colon transit, multiple.
    91020Gastric motility (manometric) studies.
    91022Duodenal motility (manometric) study.
    91112Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report.
    0106UGastric 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
    inv-06: Scintigraphy duration — At least 4 hours recommended
    Recommended minimum durationAt least 4 hours for gastric emptying scintigraphy (four-hour study preferred over shorter studies)
    ReasoningFour-hour studies have superior diagnostic accuracy compared with two-hour (or shorter) studies, per professional guidance
    Applies toSolid-meal gastric emptying scintigraphy (and aligns with C13 breath testing guidance)

    Provider Actions, Prior Authorization, and Documentation

    Prior Authorization

    Prior authorization may be required for listed diagnostic codes

    Tests such as gastric emptying scintigraphy (CPT codes 78264–78266), wireless motility capsule (CPT 91112), and C13 breath testing (CPT 0106U) are listed as related codes and may be subject to plan prior authorization consistent with the medical necessity criteria in this policy.

    • Providers should confirm prior authorization requirements with Select Health before scheduling these diagnostic tests.
    Step Therapy

    Routine evaluation and management is an alternative covered service

    Routine evaluation and management by a network health care provider is identified as an alternative covered service to diagnostic testing for suspected gastroparesis; no mandatory step-therapy sequence for diagnostic tests is specified in the policy.

    • Consider clinician evaluation and management visits as an alternative prior to ordering physiologic testing when appropriate.
    Documentation Required

    Required clinical documentation for diagnostic testing

    Document the presence of symptoms suggestive of gastroparesis, exclusion of mechanical gastric outlet obstruction (for example, via endoscopy or barium contrast study), non-diagnostic basic clinical investigations, and evaluation by a gastroenterologist trained to interpret results.

    • Record specific symptoms (nausea, vomiting, early satiety, postprandial fullness, bloating, upper abdominal pain).
    • Include results demonstrating absence of mechanical obstruction (eg, endoscopy or barium study).
    • Include documentation that basic investigations were non-diagnostic prior to physiologic testing.
    • Note that evaluation was performed by a gastroenterologist trained to use and interpret the chosen diagnostic test.
    Denial Risk

    Denial triggers related to documentation and testing

    Claims may be denied if documentation does not show symptomatic suspicion of gastroparesis, mechanical obstruction has not been excluded, or basic investigations (including upper endoscopy) are not documented as non-diagnostic prior to physiologic testing.

    • Absence of documented gastroparesis symptoms is a denial trigger.
    • Failure to document exclusion of mechanical gastric outlet obstruction (eg, endoscopy or barium contrast) may result in denial.
    • Missing documentation that basic clinical investigations were non-diagnostic prior to ordering physiologic testing can lead to denial.
    • Delayed gastric emptying must be documented by an accepted test (4-hour scintigraphy or approved alternatives) to support medical necessity.

    Background

    Gastroparesis is a gastric motility disorder defined by delayed gastric emptying without mechanical obstruction. Clinically, it typically presents with symptoms such as nausea, vomiting, early satiety, postprandial fullness, bloating, weight loss, and upper abdominal pain. Diagnosis requires documentation of delayed gastric emptying and exclusion of mechanical gastric outlet obstruction; symptoms are usually present for at least three months before making the diagnosis.

    Definitions

    inv-12: Gastroparesis — definition highlighting delayed gastric emptying of solids/fluids without obstruction
    DefinitionGastroparesis is a gastric motility disorder characterized by delayed gastric emptying of fluids and/or solids without evidence of a mechanical gastric outlet obstruction, lasting for at least three months.
    Common symptomsNausea, vomiting, early satiety, postprandial fullness, bloating, weight loss, and upper abdominal pain
    Diagnostic requirementRequires documentation of delayed gastric emptying and exclusion of other potential causes (e.g., mechanical obstruction)
    inv-13: Four-hour scintigraphy — standard diagnostic test recommendation (measure over at least four hours)
    Standard diagnostic testGastric emptying scintigraphy of a solid-phase meal measured over at least four hours is recommended as the standard diagnostic test for solid meal gastric emptying.
    Comparative guidanceFour-hour scintigraphy is preferred because shorter (two-hour or less) studies have inferior diagnostic accuracy.
    AlternativesIf scintigraphy is contraindicated or not feasible, consider wireless motility capsule or C13 breath testing, but scintigraphy remains the standard.
    Policy Summary
    Payerselect_health
    PolicyGastroparesis Evaluations
    Policy CodePolicy CCP.1357
    Change TypeNo material changes
    Effective DateMar 1, 2022
    Last ReviewFeb 1, 2026
    Next Review DateJun 1, 2027
    Key ActionDocument gastroparesis symptoms, exclude mechanical gastric outlet obstruction (e.g., endoscopy), complete non-diagnostic basic investigations, and obtain gastroparesis testing results interpreted by a trained gastroenterologist.
    SourceLink
    On This Page
    Coverage Criteria for Gastroparesis EvaluationCoding and Test ParametersProvider Actions, Prior Authorization, and DocumentationBackgroundDefinitions