CurrentUnitedHealthcarePolicy CS046OH.D

Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Ohio Only)

State-specific UnitedHealthcare medical policy for Ohio governing diagnostic testing and treatments for gastrointestinal motility disorders (including gastroparesis, constipation, anorectal disorders, fecal incontinence), listing covered, unproven, and excluded procedures and referenced clinical criteria and codes. Applies to coverage determinations and DMEPOS rules per Ohio Administrative Code.

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Motility Disorders, Diagnosis and Treatment (for Ohio Only)

Policy CodePolicy CS046OH.D

Change TypeMaterial revisions and coding updates (additions/removals); unproven procedure additions

Effective DateOctober 1, 2025

Next Review Date

Key ActionProviders must follow InterQual® CP: Procedures, Gastric Stimulation for medical necessity clinical coverage criteria for gastric electrical stimulation.

POLICY UPDATE CHANGES

Added language that Esophageal Mucosal Integrity Testing by electrical impedance (e.g., MiVu) for diagnosis of GERD, EoE, non-GERD, or for monitoring treatment response in GERD and EoE are unproven and not medically necessary due to insufficient evidence.

Removed language indicating certain colorectal function studies (rectal manometry, rectal sensation/tone/compliance, anorectal manometry, conventional defecography) were proven and medically necessary.

Added language indicating Esophageal Mucosal Integrity Testing by electrical impedance (e.g., MiVu) for diagnosis or monitoring of GERD and EoE is unproven and not medically necessary.

Removed language indicating rectal manometry, rectal sensation, tone, compliance test, and anorectal manometry are proven and medically necessary for evaluation of colorectal function.

Replaced electrogastrography wording to include body surface gastric mapping (e.g., Gastric Alimetry System, G-Tech Gut Tracker) for diagnosing intestinal or gastric disorders including Gastroparesis.

Added definition of 'Esophageal Mucosal Integrity Testing'.

Removed definitions of Anorectal Manometry, Colonic Manometry, and Defecography.

Added CPT codes 43499 and 76498 to applicable codes.

Removed CPT/HCPCS codes 74270, 76496, 91117, 91120, 91122, A9286, A9900, A9999, and E1399 from applicable codes.

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

Archived previous policy version CS046OH.C.

3Unproven procedures listed

1Proven therapy (GES) indications

17Applicable reference codes

2New CPT codes added

10CPT/HCPCS codes removed

Coverage Summary

This is UnitedHealthcare policy number CS046OH.D, effective October 1, 2025, applicable to the state of Ohio only. The policy addresses diagnosis and treatment of gastrointestinal motility disorders including gastroparesis, constipation, fecal incontinence, and anorectal disorders. UnitedHealthcare deems gastric electrical stimulation (GES) proven and medically necessary for specified indications (refractory gastroparesis or chronic intractable drug-refractory nausea and vomiting secondary to diabetic or idiopathic gastroparesis) per InterQual criteria. Several procedures are designated unproven / not medically necessary (examples: MRI defecography for evaluating constipation or anorectal/pelvic floor disorders; cutaneous/mucous/serosal electrogastrography, electroenterography, or body surface gastric mapping such as Gastric Alimetry or G-Tech Gut Tracker for diagnosing gastric or intestinal disorders including gastroparesis; and esophageal mucosal integrity testing by electrical impedance such as MiVu™ for GERD, EoE, nonacid reflux, or for monitoring treatment response).

Key Facts

Proven TherapyGastric Electrical Stimulation (Enterra) — proven/medically necessary for refractory gastroparesis and chronic intractable (drug-refractory) nausea and vomiting (diabetic or idiopathic) per InterQual reference

Unproven ProceduresMRI defecography; Electrogastrography/Body Surface Gastric Mapping (EGG/BSGM) devices (e.g., Gastric Alimetry, G-Tech Gut Tracker); Esophageal Mucosal Integrity Testing by electrical impedance (e.g., MiVu)

StateOhio (policy applies only to the state of Ohio)

Policy NumberCS046OH.D

Effective Date2025-10-01

StatusCURRENT

Medical-Necessity Criteria

Medically Necessary: Gastric Electrical Stimulation (GES)

GES therapy is proven and medically necessary when used for:

ALL of the following

Indications: Refractory gastroparesis that has failed other therapies OR chronic intractable (drug-refractory) nausea and vomiting secondary to gastroparesis of diabetic or idiopathic etiology
GES uses and indications as described by InterQual and FDA HDE labeling

Esophageal Mucosal Integrity Testing (Electrical Impedance / MiVu)

Coverage determination based on available evidence:

Esophageal Mucosal Integrity Testing (MI): Esophageal mucosal integrity testing by electrical impedance (e.g., MiVu Mucosal Integrity Testing System) for diagnosis of GERD, eosinophilic esophagitis (EoE), nonacid reflux disease (non-GERD), or for monitoring treatment response in GERD and EoE is considered unproven and not medically necessary due to insufficient evidence of efficacy.

Coding

Referenced CPT/HCPCS/Unlisted codes (reference only)mixed

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.
43647	Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum.
43648	Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum.
43881	Implantation or replacement of gastric neurostimulator electrodes, antrum, open.
43882	Revision or removal of gastric neurostimulator electrodes, antrum, open.
64590	Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver.
64595	Revision or removal of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, with detachable connection to electrode array.
72195	Magnetic resonance imaging, pelvis; without contrast material(s).

1–10 of 15

1/2

Added CPT codesCPT

43499
76498

Removed CPT/HCPCS/Nonspecific codesmixed

74270
76496
91117
91120
91122
A9286
A9900
A9999
E1399

Regulatory / device product codes mentionedmixed

MYE / FFX	FDA product codes for cutaneous electrogastrography/electroenterography/BSGM devices (informational)
LNH	FDA product code for MRI systems (informational for MRI defecography)
QIS	MiVu product code (for FDA 510(k) lookup)

Provider Actions and Billing Guidance

Documentation Required

Reference InterQual criteria for GES

Providers must follow the InterQual® CP: Procedures, Gastric Stimulation criteria when assessing medical necessity for gastric electrical stimulation (GES).

Documentation Required

State rule evaluation for unproven/limited services

Requests for services identified as unproven or that have coverage or quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-101; this policy applies only to the state of Ohio.

Background and Evidence Summary

Background: The policy covers a range of gastrointestinal motility disorders — including Gastroparesis, Constipation, Fecal Incontinence, and other Anorectal Disorders — that often require specialized testing to establish pathophysiology. Diagnostic modalities discussed include gastric emptying scintigraphy (scintigraphy noted as the reference standard for measurement of gastric emptying), surface techniques to record gastric myoelectrical activity such as Electrogastrography (EGG) and higher-resolution body surface gastric mapping (BSGM), and imaging for defecatory disorders including MRI Defecography. Society guideline context: ACG and ASCRS/ASCRS-related guidance recognize anorectal testing (e.g., ARM, BET) and defecography in selected circumstances but note limitations and that seated fluoroscopic defecography often has the most construct validity for evacuation; MRI defecography offers soft-tissue detail but evidence is insufficient to replace conventional evacuation proctography.

Citation	Design / Key finding / Limitation
Cassidy et al. 2024
Retrospective single-center case series (n=157) reported sustained symptom reduction, fewer hospitalizations and less medication use after GES; limitation: retrospective, single-center, no comparison group.
Gourcerol et al. 2023
Observational two-cohort study (n=64) comparing GES vs G-POEM found no significant difference in nausea/vomiting outcomes at 24 months; limitations: nonrandomized, small sample, baseline severity differences.
Hayes HTA 2018/2022
Hayes HTA (2018, updated 2022) concluded GES effectiveness remains uncertain; evidence low quality; device appears generally safe but complications and device removals reported.
Systematic reviews
Systematic reviews/meta-analyses (Rajamanuri 2021; Levinthal & Bielefeldt 2017; Lal 2015) show mixed evidence: open-label studies report symptom improvement but randomized/blinded trials provide limited confirmation; overall limited high-quality evidence and need for more RCTs.
ECRI 2024
ECRI (2024) assessment rated Gastric Alimetry evidence very low quality; found no direct clinical utility studies demonstrating improved patient outcomes with Alimetry-guided care.
Hayes assessments 2022/2024
Hayes evolving evidence reviews (MiVu 2022, updated 2024) found limited, very-poor-quality studies and insufficient evidence for clinical utility; weak guideline support.
MRI defecography evidence
Multiple studies and meta-analyses report insufficient or mixed evidence comparing MR defecography to conventional (fluoroscopic) defecography: some show lower technical success, variable concordance, and MRD not superior to fluoroscopy; clinical utility not established.
Multiple BSGM/EGG studies
Multiple observational and cohort BSGM/EGG studies (2019–2024) show improved phenotyping and symptom correlations vs gastric emptying testing but lack evidence that testing improves patient outcomes; systematic reviews note heterogeneity and low-to-very-low quality evidence.

Definitions: Gastroparesis — a digestive disorder with abnormal or absent stomach motility (delayed gastric emptying). Electrogastrography (EGG) — noninvasive measurement of gastric myoelectrical activity using cutaneous abdominal electrodes. MRI Defecography — noninvasive MRI imaging obtained during stages of defecation to evaluate pelvic floor anatomy, dynamic motion, and rectal evacuation. Anorectal Disorders — structural or functional abnormalities of the anorectum or pelvic floor. Constipation — infrequent or hard-to-pass bowel movements; infrequent defined as less than three bowel movements per week. Fecal Incontinence (FI) — inability to control bowel movements causing unexpected stool leakage. HDE (Humanitarian Device Exemption) — FDA pathway permitting marketing of devices for rare conditions with required facility-level IRB oversight. Esophageal Mucosal Integrity Testing — adjunct electrical-impedance testing (e.g., MiVu™) intended to assess esophageal mucosal integrity to help differentiate GERD, EoE, and non-GERD. InterQual — proprietary UnitedHealthcare clinical criteria used for primary medical/surgical coverage determinations. ASAM — American Society of Addiction Medicine criteria used for substance use disorder coverage determinations. OAC — Ohio Administrative Code; state rules governing coverage evaluation for Ohio members.

Revision History

10/01/2025material_change_addedLatest

Added language declaring Esophageal Mucosal Integrity Testing by electrical impedance (e.g., MiVu Mucosal Integrity Testing System) for diagnosis of GERD, EoE, non-GERD, or monitoring treatment response in GERD and EoE as unproven and not medically necessary due to insufficient evidence of efficacy.

10/01/2025material_change_removedLatest

Removed language indicating rectal manometry, rectal sensation/tone/compliance testing, anorectal manometry, and conventional defecography (for specified colorectal evaluations) were proven and medically necessary for evaluation of colorectal function.

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Motility Disorders, Diagnosis and Treatment (for Ohio Only)

Policy CodePolicy CS046OH.D

Change TypeMaterial revisions and coding updates (additions/removals); unproven procedure additions

Effective DateOctober 1, 2025

Next Review Date

Key ActionProviders must follow InterQual® CP: Procedures, Gastric Stimulation for medical necessity clinical coverage criteria for gastric electrical stimulation.

On This Page

Hayes and ECRI assessments conclude limited/very poor-quality evidence and lack of clinical utility studies.

Defecography and Anorectal Testing (contextual evidence summary)

Guideline-based statements describing comparative utility:

Guideline Statements

ACG ARM/BET Guidance: ACG: ARM and BET may confirm or exclude defecatory disorders when clinical features suggest DD; ARM and BET results may be equivocal (moderate recommendation).
ACR/ASCRS MRI vs Fluoroscopic Defecography: ACR/ASCRS: MRI defecography has advantages (soft tissue resolution) but fluoroscopic defecography performed seated is considered the evacuation exam with most construct validity (conditional/strong recommendations depending on context).

Documentation Required

Do not rely on EGG/BSGM or MI as proven diagnostics

When ordering or interpreting electrogastrography (EGG), body surface gastric mapping (BSGM), or esophageal mucosal integrity (MI) testing, document that these tests are considered investigational or unproven and lack demonstrated clinical utility; anticipate medical necessity denial where this policy applies.

Documentation Required

Enterra HDE institutional oversight

Enterra (the GES device marketed under an HDE) may only be used with institutional IRB approval at the facility for the specific rare disease and facilities should follow FDA labeling contraindications for Enterra.

Billing Rule

Applicable code list updated

Applicable code list was revised. The policy added CPT codes and removed several CPT/HCPCS codes from the applicable codes list.

Added: 43499, 76498
Removed: 74270, 76496, 91117, 91120, 91122, A9286, A9900, A9999, E1399

Documentation Required

Policy versioning and reference updates

Providers should reference the current policy number CS046OH.D, effective October 1, 2025, for coverage criteria, requirements, and the most current policy information.

Documentation Required

Reference applicable federal/state/contractual requirements & Use InterQual/ASAM criteria

When making coverage decisions, reference applicable federal, state (Ohio Administrative Code), or contractual requirements first; use InterQual for primary medical/surgical criteria and ASAM for substance use disorders as applicable. If InterQual lacks criteria, UnitedHealthcare may use its own approved policies and guidelines.

Denial Risk

Esophageal Mucosal Integrity Testing — Not Medically Necessary

Esophageal mucosal integrity testing by electrical impedance (e.g., MiVu) is considered unproven and not medically necessary for diagnosing GERD, EoE, non-GERD, or for monitoring treatment response; expect denials where this policy is applied.

Documentation Required

Rectal/anorectal and defecography language removed/updated

Language indicating that rectal manometry, rectal sensation/tone/compliance testing, anorectal manometry, and conventional defecography were previously proven/medically necessary has been removed or narrowed; prior proven/medically necessary wording for certain colorectal function tests was removed/updated.

Documentation Required

Policy updates and professional judgment

UnitedHealthcare may modify policies and guidelines; medical policies are informational and intended to be used in conjunction with independent professional medical judgment of qualified health care providers.

10/01/2025material_change_revisedLatest

Replaced wording for electrogastrography to explicitly include body surface gastric mapping (e.g., Gastric Alimetry System, G-Tech Gut Tracker) among investigational/unproven tests for diagnosing intestinal or gastric disorders including Gastroparesis.

10/01/2025material_change_added_codesLatest

Added CPT codes 43499 (Unlisted procedure, esophagus) and 76498 (Unlisted magnetic resonance procedure) to the applicable codes list.

10/01/2025material_change_removed_codesLatest

Removed CPT/HCPCS codes 74270, 76496, 91117, 91120, 91122, A9286, A9900, A9999, and E1399 from the applicable codes list.

10/01/2025archived_previous_versionLatest

Archived previous policy version CS046OH.C.

10/01/2025otherLatest

Updated Description of Services, Clinical Evidence, FDA, and References sections to reflect current information; clarified applicability to Ohio and use of Ohio Administrative Code for evaluation of unproven services.