CurrentUnitedHealthcarePolicy CS046OH.E

Gastrointestinal Disorders Diagnostic Procedures (for Ohio Only)

State-specific UnitedHealthcare medical policy (Ohio only) describing coverage determinations and evidence review for various GI diagnostic procedures including MRI defecography, electrogastrography/BSGM, mucosal integrity testing, and FLIP; lists procedures considered unproven/not medically necessary and provides definitions and referenced codes.

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Disorders Diagnostic Procedures (for Ohio Only)

Policy CodePolicy CS046OH.E

Change TypeRevised (title/content relocations, code removals, additions to unproven list)

Effective DateApr 1, 2026

Next Review Date

Key ActionFor services stated as unproven or subject to coverage/quantity limits, evaluate medical necessity using Ohio Administrative Code 5160-101 and document rationale; obtain prior authorization as applicable.

POLICY UPDATE CHANGES

Title changed from 'Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Ohio Only)'.

Removed and relocated language pertaining to gastric electrical stimulation (GES) therapy to a separate Medical Policy.

Revised list of unproven and not medically necessary procedures: added 'Functional Lumen Imaging Probe (FLIP) technology for diagnosing Achalasia'. Also removed examples listing certain EGG/BSGM systems and MiVu MI system from examples list.

Applicable CPT codes 43647, 43648, 43881, 43882, 64590, and 64595 removed.

Updated Supporting Information sections (Description of Services, Clinical Evidence, FDA, References) to current evidence.

4Unproven/not medically necessary listed

9Referenced procedure codes

insufficientClinical utility demonstrated

2026-04-01Last revision date

multipleStudies summarized

Coverage Summary

State-specific Ohio UnitedHealthcare medical policy (CS046OH.E) describes coverage determinations and evidence review for diagnostic procedures including MRI defecography, electrogastrography/body surface gastric mapping (EGG/BSGM), esophageal mucosal integrity (MI) testing, and Functional Lumen Imaging Probe (FLIP). The policy lists these procedures as unproven and not medically necessary due to insufficient evidence of efficacy and specifies that the policy applies only to Ohio with evaluation of such services performed under Ohio Administrative Code 5160-101. The coverage stance is mixed. The policy effective date is 2026-04-01. The brief notes 4 procedures listed as unproven/not medically necessary in this section, references 9 procedure codes, summarizes multiple small studies for BSGM/EGG/MI, and concludes that clinical utility is insufficient (policy last revised 04/01/2026).

Policy facts

Policy regionOhio only

Policy numberCS046OH.E

Effective date2026-04-01

StatusCURRENT

Medical-Necessity & Not Medically Necessary Criteria

Unproven / 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

Coding / Applicable Codes

Referenced Procedure / Unlisted Codesmixed

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 imaging, pelvis; without contrast.
72196	Magnetic resonance imaging, pelvis; with contrast.
72197	Magnetic resonance imaging, pelvis; without followed by with contrast 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 codes (policy revision)CPT

43647
43648
43881
43882
64590
64595

Device product codes referenced (FDA product codes)mixed

MYE	Product code for cutaneous electrogastrography/electroenterography/BSGM instruments
FFX	Product code referenced for radiopaque markers and other devices
QIS	Product code for MiVu Mucosal Integrity Testing System

Billing Rule

Policy changes affecting coding

Providers should note the removal of the following CPT codes from the policy effective 04/01/2026 and update coding/billing practices accordingly.

43647
43648
43881
43882
64590
64595

Provider Actions & Authorization

Prior Authorization

Prior authorization implication for unproven procedures

Requests for procedures identified in this policy as unproven or not medically necessary may be subject to denial and/or require review under Ohio Administrative Code 5160-101. Providers should obtain prior authorization as applicable because services described as unproven may not meet medical necessity criteria and could be denied.

Documentation Required

Ohio-specific medical necessity evaluation

This policy applies only to Ohio. For services stated as unproven or subject to coverage/quantity limits, evaluate medical necessity using Ohio Administrative Code 5160-101 and document the clinical rationale per state rule when submitting requests.

Background & Evidence Summary

Constipation, fecal incontinence, gastroparesis, and anorectal disorders can arise from structural or functional abnormalities; clinical correlation with history and physical examination (including digital rectal exam) is essential before labeling findings as clinically significant. Scintigraphy remains the reference standard for measurement of gastric emptying and standardized protocols (adequate test meals, duration) are required for interpretation. Anorectal testing and dynamic imaging are used to evaluate rectal evacuation and pelvic floor function when indicated, but results must be interpreted in the clinical context.

Electrogastrography (EGG) is a noninvasive surface recording of gastric myoelectrical activity obtained with cutaneous electrodes; electroenterography and high-resolution body surface gastric mapping (BSGM) use expanded electrode arrays and analytics to map gastric slow waves. FLIP (EndoFLIP) is a catheter-based impedance planimetry system measuring luminal diameter and distensibility at the esophagogastric junction to provide adjunctive information during endoscopy. Magnetic resonance (MR) defecography obtains static and dynamic images through stages of defecation to assess pelvic floor anatomy, motion, and rectal evacuation.

Source	Summary
ECRI (2024)	Clinical evidence assessments for EndoFLIP and Gastric Alimetry concluded available studies are limited/very-low quality; insufficient direct clinical utility evidence that testing improves patient outcomes; additional larger validation studies needed.
Hayes (2019/2022/2024)	Evidence analyses/HTAs found insufficient high-quality RCTs and limited support for clinical utility of EndoFLIP and MiVu MI testing; recommended continued monitoring and further research.
Systematic reviews (MRI defecography)	Meta-analyses conclude MRI defecography is not superior to fluoroscopic/evacuation proctography for many outcomes; sensitivity depends on inclusion of evacuation phase; does not replace reference standard but may serve as a triage test.
Peralta-Palmezano et al. (2024)	Systematic review/meta-analysis of EGG in gastroparesis (31 studies, 1545 patients) found altered gastric slow waves in gastroparesis versus controls (less normogastria, more bradygastria/tachygastria) but heterogeneity and protocol differences limit conclusions; clinical utility not shown.
Wang et al. (2024)	Exploratory comparison (n=75) found BSGM spectral analysis detected motility abnormalities at 33.3% vs GET 22.7%; BSGM phenotypes correlated better with symptom indices and psychometrics than GET; study did not demonstrate improved patient outcomes.
Schamberg et al. (2023)	Multicenter retrospective study (n=178) showed BSGM had substantially improved symptom correlations and higher patient-level classification accuracy versus EGG (BSGM accuracy 0.78 vs EGG 0.54 for patients vs controls; vs blinded panel 0.96 vs 0.43); limitations include retrospective design and heterogeneity.
Xu et al. (2024/2023)	Small cohort studies using BSGM reported correlations between gastric myoelectrical abnormalities and symptoms in post-fundoplication patients and longstanding T1D; sample sizes small and clinical utility (impact on outcomes) not demonstrated.
Patel 2019 / Choksi 2018	Balloon mucosal impedance (MI) studies differentiated GERD, EoE, and non-GERD in small prospective/retrospective cohorts with distinct MI patterns, but studies limited by small size, lack of broad validation, and no demonstrated impact on clinical outcomes.
Hayes / ECRI reviews (BSGM, MI, EndoFLIP)	Independent review organizations summarize limited, low-quality evidence across device types (EndoFLIP, Gastric Alimetry, MiVu); recommend more robust studies and note lack of established clinical utility to change management or improve outcomes.
Systematic reviews / meta-analyses cited in policy (various)	Multiple systematic reviews/meta-analyses identify methodological heterogeneity, small studies, and inconsistent protocols across EGG/BSGM and MRI defecography literature, resulting in insufficient evidence to establish routine clinical use or superiority over reference standards.
Policy summary / Evidence-based conclusions	Overall policy conclusion: EGG/BSGM, MRI defecography, MI testing, and FLIP are considered unproven or not medically necessary for routine use due to insufficient evidence of clinical utility despite some promising diagnostic/phenotyping signals in small studies.

Key definitions

AchalasiaA primary esophageal motor disorder with impaired esophagogastric junction relaxation and loss of organized peristalsis.

Anorectal DisordersStructural or functional abnormalities of the anorectum or pelvic floor.

Evidence-Based Conclusions

BSGM (e.g., Gastric Alimetry) has demonstrated improved patient phenotyping and stronger correlations with symptoms compared with gastric emptying testing (GET) and traditional low-resolution EGG in multiple small studies, but the evidence does not demonstrate that BSGM use improves patient outcomes or clinical utility.

Traditional EGG and related cutaneous myoelectrical tests remain experimental or inconclusive for routine clinical use because of heterogeneous methods, inconsistent symptom correlations, and lack of standardization.

Esophageal mucosal integrity (MI) testing shows limited and preliminary evidence that patterns can distinguish GERD, EoE, and non-GERD in small studies, but overall evidence is insufficient to demonstrate clinical utility or that MI testing improves outcomes; professional guidelines do not endorse routine use.

MRI defecography has insufficient evidence of superiority to fluoroscopic/evacuation proctography; systematic reviews and comparative studies find MRD is not clearly better than fluoroscopic defecography and may be inferior for some outcomes, and its results should not be the sole basis for treatment decisions.

Revision History

04/01/2026material_changeLatest

Title changed and content reorganized; GES language relocated; CPT codes removed; FLIP added to list of unproven procedures; examples of specific systems removed; definitions added; supporting information updated and other content removed/relocated as summarized in policy revision notes.

04/01/2026title_changeLatest

Policy title changed from 'Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Ohio Only)' to 'Gastrointestinal Disorders Diagnostic Procedures (for Ohio Only)'.

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Disorders Diagnostic Procedures (for Ohio Only)

Policy CodePolicy CS046OH.E

Change TypeRevised (title/content relocations, code removals, additions to unproven list)

Effective DateApr 1, 2026

Next Review Date

On This Page

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Application

This Medical Policy only applies to the state of Ohio. Evaluation of unproven or limited services per Ohio Administrative Code 5160-101.

ALL of the following

Policy applies only to Ohio; requests for services stated as unproven or subject to coverage/quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-101

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Evidence-based conclusions for BSGM/EGG and MI testing

Summary statements and limitations from studies and guideline positions:

ALL of the following

BSGM (e.g., Gastric Alimetry) shows improved patient phenotyping and stronger symptom correlations compared with gastric emptying testing (GET) and traditional EGG in multiple small studies, but clinical utility in improving patient outcomes is not demonstrated.
Studies cited (Xu 2024; Wang 2024; Xu 2023; Schamberg 2023; Gharibans 2022; Bhat 2021 and others) have limitations including small sample sizes, lack of blinding, heterogeneity of methods, and limited generalizability.
Electrogastrography (low-resolution/transcutaneous EGG) is considered experimental/inconclusive for routine clinical use by guideline statements and existing evidence; EGG lacks consistent symptom correlations and patient-level diagnostic accuracy versus BSGM.
Esophageal mucosal integrity testing (balloon MI, MiVu) has limited evidence; some studies show MI patterns can distinguish GERD, EoE, and non-GERD, but overall evidence is insufficient to demonstrate clinical utility or that testing improves outcomes.
Professional guidelines (AGA, ACG) do not recommend routine use of EGG or consider MI testing sufficiently developed for guideline endorsement.

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title_final__Evidence-based conclusions for BSGM/EGG and MI testing

Documentation Required

Evidence and clinical utility documentation required

Because studies do not demonstrate that BSGM, EGG, MI testing, or FLIP improve patient outcomes, providers ordering these tests should document the specific clinical rationale for testing and explicitly state how test results are expected to change patient management. Include relevant clinical findings and planned management changes in the record to support medical necessity.

Prior Authorization

Use applicable benefit rules and InterQual

UnitedHealthcare uses InterQual for primary medical/surgical criteria. If InterQual does not have applicable criteria, use UnitedHealthcare Medical Policies/Coverage Determination Guidelines as approved by Ohio Medicaid. Verify whether prior authorization is required per the member's contract and applicable state or federal rules before ordering services.

ConstipationInfrequent (<3/week) or hard-to-pass bowel movements or hard stools; may include sensation of incomplete evacuation.

EGGElectrogastrography (EGG): noninvasive measurement of gastric myoelectrical activity using cutaneous/transcutaneous electrodes.

MIMucosal Impedance/Integrity testing (MI): measurement of esophageal mucosal impedance (e.g., balloon catheter) during endoscopy as an adjunct to differentiate GERD, EoE, and non-GERD.

FLIPFunctional Lumen Imaging Probe (FLIP): catheter-based impedance planimetry system assessing luminal dimensions and distensibility (eg, EGJ distensibility index) as an adjunct during endoscopy.

GastroparesisDelayed gastric emptying with associated symptoms; scintigraphy is the reference standard for gastric emptying measurement.

MRI DefecographyMagnetic resonance defecography: MRI imaging obtained during stages of defecation to evaluate pelvic floor anatomy, dynamic motion, and rectal evacuation.

BSGMBody Surface Gastric Mapping (BSGM): noninvasive high-resolution measurement of gastric myoelectrical activity using electrode arrays and analytics (eg, Gastric Alimetry).

GESGastric Electrical Stimulation (GES): therapy previously referenced in this policy but relocated to a separate policy; not covered here.

Language pertaining to gastric electrical stimulation (GES) therapy removed from this policy and relocated to the Medical Policy 'Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Ohio Only)'.

04/01/2026codes_removedLatest

Applicable CPT codes 43647, 43648, 43881, 43882, 64590, and 64595 were removed from the policy's Applicable Codes list.

04/01/2026coverage_criteria_revisionLatest

Revised list of procedures considered unproven/not medically necessary to add 'Functional Lumen Imaging Probe (FLIP) technology for diagnosing Achalasia' and to remove specific examples of EGG/BSGM and MiVu MI system from the examples list.

04/01/2026definitions_addedLatest

Definitions for Achalasia and Functional Lumen Imaging Probe (FLIP) were added to the policy.

04/01/2026supporting_info_updateLatest

Supporting Information sections (Description of Services, Clinical Evidence, FDA, References) were updated to reflect current evidence and resources.

04/01/2026non_material_change

Removed reference to Ohio Administrative Code Rule 5160-10-01 (DMEPOS general provisions) and removed content addressing coverage limitations and exclusions.