CurrentUnitedHealthcarePolicy CS046OH.E

Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Ohio Only) – Community Plan Medical Policyopen_in_new

State-specific UnitedHealthcare medical policy for diagnostic procedures used in gastrointestinal motility and anorectal disorders in Ohio, describing which procedures are considered unproven/not medically necessary, definitions, evidence summaries, professional guideline positions, and applicable CPT/HCPCS/unlisted codes. This is part 1 of 2 and covers rationale, definitions, descriptions of services, evidence reviews for FLIP, MRI defecography, and electrogastrography/BSGM.

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Motility Disorders, Diagnosis and Treatment (for Ohio Only) – Community Plan Medical Policyopen_in_new

Policy CodePolicy CS046OH.E

Change TypeRevisions to unproven procedures list; code removals; definitions added

Effective DateApr 1, 2026

Next Review Date

Key ActionEnsure any requests for services listed as unproven or subject to coverage/quantity limits are evaluated against Ohio Administrative Code 5160-101 and document rationale per state rules.

SourceLink

POLICY UPDATE CHANGES

Title changed and Coverage Rationale language removed/relocated regarding gastric electrical stimulation (GES) therapy.

Removed reference to Ohio Administrative Code Rule 5160-10-01 (DMEPOS general provisions).

Revised list of unproven and not medically necessary procedures: added 'FLIP technology for diagnosing Achalasia'.

Removed listed examples of cutaneous/mucous/serosal EGG/BSGM device examples and MiVu mucosal integrity testing system from that list.

Removed content addressing coverage limitations and exclusions.

Added definitions for Achalasia and Functional Lumen Imaging Probe (FLIP).

Removed CPT codes 43647, 43648, 43881, 43882, 64590, and 64595 from Applicable Codes.

Updated Description of Services, Clinical Evidence, FDA, and References sections to reflect current information.

Coverage Summary

State-specific Ohio UnitedHealthcare medical policy (Policy Number: CS046OH.E) addressing diagnostic procedures used in gastrointestinal motility and anorectal disorders. This is part 1 of 2 and summarizes procedures considered unproven and not medically necessary (count = 4): Magnetic Resonance Imaging (MRI) Defecography; cutaneous/mucous/serosal Electrogastrography/electroenterography/body surface gastric mapping (EGG/BSGM); Esophageal Mucosal Integrity (electrical impedance) testing; and Functional Lumen Imaging Probe (FLIP) technology for diagnosing Achalasia. The policy effective date is April 1, 2026 and policy status is CURRENT.

Key Facts

Effective Date2026-04-01

Policy NumberCS046OH.E

State ApplicabilityOhio only

PartPart 1 of 2

Has Material ChangeYes

Medical-Necessity / Not Medically Necessary Criteria

Unproven and Not Medically Necessary Procedures

The following procedures are unproven and not medically necessary due to insufficient evidence of efficacy:

ALL of the following

Magnetic Resonance Imaging (MRI) Defecography for evaluating Constipation and Anorectal or pelvic floor disorders
Cutaneous, mucous, or serosal Electrogastrography or electroenterography or body surface gastric mapping for diagnosing intestinal or gastric disorders including Gastroparesis
Esophageal Mucosal Integrity Testing by electrical impedance for the diagnosis of gastroesophageal reflux disease (GERD), eosinophilic esophagitis (EoE), and nonacid reflux disease (non-GERD), or for the monitoring of treatment response in GERD and EoE
Functional Lumen Imaging Probe (FLIP) technology for diagnosing Achalasia

Provider Actions & Billing Impact

Documentation Required

Ohio-only applicability and medical necessity evaluation

This Medical Policy applies only to Ohio. Any requests for services identified as unproven or those subject to coverage or quantity limits must be evaluated for medical necessity using Ohio Administrative Code 5160-101. Document the clinical rationale and specific medical necessity determination per Ohio rules when submitting requests for these services.

Prior Authorization

Prior authorization may be required for unproven services

Services identified as unproven or not medically necessary in this policy (for example: MRI defecography, cutaneous/mucous/serosal electrogastrography/electroenterography/BSGM, FLIP for achalasia, and esophageal mucosal impedance testing) may be subject to benefit determination and prior authorization. Coverage and prior authorization requirements are governed by the member’s contract and applicable Ohio rules (including evaluation against OAC 5160-101).

Coding

Referenced Procedure/Unlisted and Test Codes (for reference only)CPT

0779T	Gastrointestinal myoelectrical activity study, stomach through colon, with interpretation and report.
0868T	High-resolution gastric electrophysiology mapping with simultaneous patient-symptom profiling, with interpretation and report.
43499	Unlisted procedure, esophagus.
72195	Magnetic resonance (e.g., proton) imaging, pelvis; without contrast material(s).
72196	Magnetic resonance (e.g., proton) imaging, pelvis; with contrast material(s).
72197	Magnetic resonance (e.g., proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences.
76498	Unlisted magnetic resonance procedure (e.g., diagnostic, interventional).
91132	Electrogastrography, diagnostic, transcutaneous.
91133	Electrogastrography, diagnostic, transcutaneous; with provocative testing.

Removed CPT codesCPT

43647
43648
43881
43882
64590
64595

FDA device product codes referenced (informational)mixed

MYE/FFX	Product codes for cutaneous electrogastrography/electroenterography/BSGM and radiopaque markers
QIS	Product code for MiVu Mucosal Integrity Testing System
K170833	EndoFLIP 510(k) ID

Background & Evidence

Background: The policy reviews diagnostic procedures used for gastrointestinal motility and anorectal disorders (for example, constipation, fecal incontinence, gastroparesis, and achalasia). For measurement of gastric emptying, scintigraphy is the reference standard, and the policy emphasizes the need for adherence to validated, standardized protocols (including standardized meals and adequate imaging duration) for gastrointestinal function testing. The document contains evidence reviews and summaries for FLIP (EndoFLIP), MRI defecography, and electrogastrography/BSGM, and cites professional society guidance and external evidence assessments (for example, Hayes and ECRI evaluations and AGA/ACG guidance).

Study/Source	Key finding/notes
Fehervari et al. (2025) meta-analysis on EndoFLIP intraoperative use
Included 32 studies (2681 patients) qualitative, 17 studies (1734 patients) quantitative; concluded EndoFLIP enhances achalasia treatment by providing real-time DI feedback allowing tailored interventions, but limitations: mostly retrospective, no RCTs, need for standardized protocols and unclear impact on patient-centered outcomes.
ECRI (2024) on EndoFLIP
Reviewed 12 studies (~2100 individuals); evidence limited, very-low quality with high risk of bias; insufficient to conclude clinical utility or validity of EndoFLIP for GI motility disorders; ongoing trials identified but evidence gaps remain.
Cochrane (van Gruting et al. 2021) MRI defecography vs other modalities
Systematic review/meta-analysis of 39 studies (2483 women): MRI defecography specificity high for rectocele/enterocele/intussusception but overall evidence did not support replacing evacuation proctography as reference standard; sensitivity better with evacuation phase; concluded MRI/TPUS may serve as triage tests but not reference standard.
Peralta-Palmezano et al. (2024) EGG meta-analysis
Systematic review of 31 prospective studies (1545 gastroparesis patients): patients had less normogastria and more bradygastria/tachygastria versus controls; heterogeneity of protocols and no evidence that EGG improves clinical outcomes; clinical utility unproven.
BSGM detection rate entry (Wang et al. 2024)
Exploratory comparison: BSGM detected motility abnormalities in 33.3% vs gastric emptying testing (GET) 22.7% in 75 adults; BSGM provided improved phenotyping and symptom correlations though outcome impact not addressed.
BSGM vs EGG accuracy (Schamberg et al. 2023)
Multi-center retrospective study (178 subjects) found BSGM had superior performance: patient-level classification accuracy 0.78 (vs EGG 0.54) and higher correlation with symptoms; limitations include heterogenous methods and potential proprietary processing differences.
MiVu diagnostic performance (Patel 2019; Choksi 2018; Hayes/ECRI reviews)
Small studies showed MI patterns could differentiate GERD, EoE, and non-GERD and detect mucosal integrity changes during endoscopy, but evidence limited, studies small/low quality, and clinical utility for improving outcomes not established per Hayes and ECRI reviews.

Glossary (short definitions):

Achalasia: A primary esophageal motor disorder of unknown etiology characterized by degeneration of the myenteric plexus, impaired esophagogastric junction relaxation, and loss of organized peristalsis.

Anorectal Disorders: Structural or functional abnormalities of the anorectum or pelvic floor.

Constipation: Infrequent or hard-to-pass bowel movements, hard stools, or sensation of incomplete evacuation; infrequent defined as fewer than three bowel movements per week.

Electrogastrography (EGG): A noninvasive method to measure gastric myoelectrical activity using cutaneous electrodes placed on the abdominal skin over the stomach.

FLIP: Functional Lumen Imaging Probe — a catheter-based endoscopic system that assesses esophageal motility and distensibility (measuring luminal dimensions/pressure; includes EndoFLIP devices).

Gastroparesis: A digestive disorder with abnormal or delayed gastric motility (delayed gastric emptying).

Revision History

2026-04-01revisedLatest

Title changed and Coverage Rationale language removed/relocated regarding gastric electrical stimulation (GES) therapy.

2026-04-01removedLatest

Removed reference to Ohio Administrative Code Rule 5160-10-01 (DMEPOS general provisions).

2026-04-01revised