ModifiedUnitedHealthcarePolicy CS046KS.03

Gastrointestinal Disorders Diagnostic Procedures (for Kansas Only)

This UnitedHealthcare medical policy governs the use and coverage stance for selected diagnostic procedures for gastrointestinal disorders for members in Kansas. It informs providers which procedures are considered unproven/not medically necessary and summarizes evidence and guideline context.

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Disorders Diagnostic Procedures (for Kansas Only)

Policy CodePolicy CS046KS.03

Change TypeTitle changecontent updatesadditions/removals to unproven lists and codes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionDocument clinical indication and prior testing and obtain any required prior authorization when ordering listed advanced GI diagnostic tests.

SourceLink

POLICY UPDATE CHANGES

Title changed from 'Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Kansas Only)' to the current title and coverage rationale was updated to remove and relocate language pertaining to gastric electrical stimulation (GES) therapy.

Functional Lumen Imaging Probe (FLIP) technology for diagnosing Achalasia was added to the list of unproven and not medically necessary procedures.

Specific examples of cutaneous, mucous, or serosal electrogastrography and body surface gastric mapping systems (including Gastric Alimetry System and G-Tech Gut Tracker) and MiVu mucosal integrity testing were removed from the unproven/not medically necessary list.

CPT codes 43647, 43648, 43881, 43882, 64590, and 64595 were removed from the applicable codes section.

Kansasstate-specific applicability

5procedures unproven / not medically necessary

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2new definitions added

1separate policy referenced for GES

Coverage Criteria — Unproven and Not Medically Necessary Procedures

MRI defecography (MRD) and defecography — evidence and guideline positioning relative to evacuation proctography and ultrasound

MRI defecography (MRD) has been evaluated as an imaging option for posterior pelvic floor disorders and obstructed defecation syndrome (ODS). Evidence reviews, comparative studies, and professional society guidance indicate limitations of MRD compared with evacuation proctography (EP)/fluoroscopic defecography and variable diagnostic performance depending on technique (especially whether an evacuation phase is included). The following summarizes key evidence and the resulting coverage stance.

Any use of MRI defecography (MRD) to replace evacuation proctography (EP)/fluoroscopic defecography as the routine reference-standard diagnostic test for posterior pelvic floor disorders is considered unproven and not medically necessary.

MRD may be considered a complementary or triage imaging test when performed with appropriate evacuation-phase technique and when results will directly inform management; however, MRD is NOT supported as a routine replacement for EP because: (a) pooled diagnostic accuracy indicates lower sensitivity for some findings when evacuation is not performed during MRD, (b) technical success rates and diagnostic yield are frequently lower than fluoroscopic defecography, and (c) MRD findings correlate poorly with patient-reported symptom severity and should not be used alone to dictate treatment.

MRD is considered experimental/unproven and not medically necessary for evaluation of constipation or anorectal/pelvic floor disorders when performed without an evacuation/evacuation-phase protocol or when used as the sole diagnostic imaging modality in lieu of EP or combined anorectal physiologic testing (e.g., ARM, BET) that is indicated by clinical assessment.

MRD may be reasonable as an adjunctive test in select clinical scenarios (e.g., to provide additional anatomic detail of pelvic compartments, to evaluate soft-tissue structures, or when radiation exposure must be minimized), provided that: • MRD includes dynamic imaging with an evacuation phase where clinically feasible, and • MRD results are interpreted in conjunction with clinical findings and, when appropriate, other anorectal physiologic tests (ARM, BET) and not used in isolation to determine management.

MRD should not be used as the sole basis for surgical decision-making without corroborating clinical, physiologic, or fluoroscopic findings due to variable agreement with fluoroscopic defecography for detection of enterocele, intussusception, rectocele, and dyssynergic defecation.

When MRD is performed, operational limitations and reporting considerations include: • MRD performed in the supine position may under-detect abnormalities that are better demonstrated during seated/evacuation fluoroscopic defecography, • Technical factors (amount/consistency of rectal contrast/gel, evacuation protocol) substantially affect MRD sensitivity and specificity, and • MRD protocols and interpretation lack standardized, widely adopted technique and reporting across centers; results should be interpreted by radiologists experienced in pelvic floor imaging.

Procedure and Device Codes

Referenced procedure 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 (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.

Codes referenced in textmixed

No codes listed

Device/Product Codes and 510(k) IDsmixed

MYE	FDA product code for instruments to perform cutaneous electrogastrography / electroenterography / body surface gastric mapping (informational)
FFX	FDA product code referenced for several cleared devices including radiopaque markers (informational)
QIS	FDA product code for MiVu Mucosal Integrity Testing System (informational)
K170833	FDA 510(k) ID for EndoFLIP System (informational)

Applicable Codes — removed from policyCPT

43647	removed
43648	removed
43881	removed
43882	removed
64590	removed
64595	removed

Gastric emptying reference standard — scintigraphy per standardized meal protocols

Reference standardScintigraphy using standardized meal protocols is the reference standard for objective measurement of gastric emptying in patients with suspected gastroparesis; adherence to validated, standardized study protocols (adequate meal consumption and imaging duration) is required for interpretation.

Clinical requirementDiagnosis of gastroparesis requires objective evidence of clearly delayed gastric emptying obtained with scintigraphy.

Protocol importanceClinical utility depends on complete consumption of the test meal and adequate imaging duration; standardized meal protocols are recommended.

Provider Actions, Prior Authorization, and Documentation

Denial Risk

Denial risk for unproven procedures

Services listed in this policy as unproven or not medically necessary may be subject to prior authorization and could be denied if submitted without appropriate justification. Verify benefit plan terms and any federal/state/contractual requirements prior to requesting authorization.

Inclusion of a code in this policy does not guarantee coverage or payment; plan-specific terms govern.
When a service is designated unproven or not medically necessary, prior authorization may be required or claims may be denied.

Prior Authorization

Prior authorization considerations for MRI defecography

MRI defecography is considered investigational/insufficient to replace evacuation proctography as the reference standard. It may have a triage/supplemental role when performed with an evacuation phase, but prior authorization should reflect limited evidence and the need for prior basic testing.

Background and Clinical Context

Background: Constipation, fecal incontinence, and gastroparesis are common gastrointestinal conditions that often prompt diagnostic evaluation when symptoms persist, worsen, or are refractory to conservative therapy. Scintigraphic gastric emptying testing performed with standardized meal protocols remains the reference standard for objectively diagnosing gastroparesis. Advanced tests discussed in this policy (FLIP, MR defecography, EGG/BSGM, and mucosal impedance) are emerging or adjunctive tools; their roles should be considered in the context of prior clinical evaluation, conservative management, and established diagnostic pathways.

Definitions

Achalasia — definition of achalasia

DefinitionA primary esophageal motor disorder characterized by degeneration of the myenteric plexus resulting in impaired relaxation of the esophagogastric junction and loss of organized peristalsis.

Source attributionDefinition referenced from ASGE description in policy definitions section.

Clinical implicationRepresents a disorder for which diagnostic tools (e.g., manometry, FLIP) may be used as part of evaluation, but tool-specific roles vary per guidelines.

Electrogastrography (EGG) — definition of EGG

DefinitionA non‑invasive method for the measurement of gastric myoelectrical activity using cutaneous electrodes placed on the abdominal skin over the stomach.

Typical useHistorically used to detect gastric dysrhythmias and assess gastric myoelectrical patterns in research and clinical investigations.

Revision History and Policy Changes

2026-04-01Title change and content updateLatest

Policy title changed from 'Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Kansas Only)' and coverage rationale updated; language pertaining to gastric electrical stimulation (GES) therapy was removed and relocated to a separate medical policy.

2026-04-01FLIP added to unproven list

Functional Lumen Imaging Probe (FLIP) technology was added to the list of procedures considered unproven and not medically necessary for diagnosing achalasia.

2026-04-01

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Disorders Diagnostic Procedures (for Kansas Only)

Policy CodePolicy CS046KS.03

Change TypeTitle changecontent updatesadditions/removals to unproven lists and codes

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionDocument clinical indication and prior testing and obtain any required prior authorization when ordering listed advanced GI diagnostic tests.

SourceLink

On This Page

MRI defecography may confirm diagnoses (rectocele, enterocele, intussusception) when positive but is less sensitive without an evacuation phase.
Prior authorization requests for MRI defecography should document why conventional testing is inadequate or inconclusive.

Prior Authorization

Device/Product testing may require prior review

Devices and device-based tests described in this policy (e.g., electrogastrography systems, body surface gastric mapping devices, mucosal integrity testing systems, FLIP/EndoFLIP) may be FDA-regulated and, when billed, could require prior review or authorization under the member's benefit plan.

Confirm device regulatory status (FDA product code / 510(k)/de novo) when submitting requests.
Device clearance does not by itself establish coverage — submit clinical rationale and any supporting literature.

Documentation Required

Documentation expectations and clinical context

Document clinical context, prior conservative care, and prior diagnostic testing before requesting advanced imaging or device-based tests for defecatory disorders and gastroparesis. Lack of documented prior evaluation or objective evidence may lead to denial.

For gastroparesis: provide objective evidence of delayed gastric emptying by scintigraphy using validated standardized protocols prior to advanced/novel testing.
For defecatory disorders: document failure of conservative measures (diet, fiber, osmotic laxatives) and results of anorectal testing (ARM, BET) before imaging is requested.
When mucosal impedance (MI) testing is used, include EGD findings and how MI results will change management; MI alone is insufficient to establish coverage.

Prior Authorization

Conservative care before advanced testing

Conservative care and basic anorectal testing are expected before advanced imaging for defecatory disorders. Imaging (fluoroscopic defecography or MRI defecography) is appropriate when ARM and BET are inconclusive or when structural causes are suspected.

Conservative measures: dietary modification, fiber therapy, osmotic laxatives, and other standard noninvasive management.
Basic testing prior to imaging: anorectal manometry (ARM) and balloon expulsion test (BET).
Fluoroscopic defecography in the seated position remains the evacuation standard; MRI may be useful for additional soft-tissue assessment.

Documentation Required

Recommended contextual documentation for MI testing

For mucosal integrity (MI) testing performed during EGD, include endoscopic findings, indication for biopsy or pH testing, and how MI measurements will alter diagnostic or therapeutic decisions. Limited evidence for MI as a sole diagnostic tool may trigger denial if used without corroborating clinical data.

Submit EGD report, any biopsy or pH testing results, and the clinical question MI is intended to answer.
Clinical utility (impact on management) must be demonstrated; single small studies do not establish sufficiency.

Prior Authorization

Diagnostic sequencing for gastroparesis

Scintigraphy is the reference standard for diagnosing gastroparesis; prior authorization or coverage review should require objective scintigraphic evidence of delayed gastric emptying and adherence to validated meal and imaging protocols before considering alternative or investigational tests.

Ensure complete consumption of standardized test meal and adequate imaging duration are documented in the record.
Novel gastric electrophysiology or surface mapping tests are considered investigational and lack sufficient evidence for routine coverage.

Step Therapy

No step therapy specified

No specific step therapy requirements are described in this policy for the technologies addressed. Verify the member's benefit plan for any plan-specific step therapy or prior authorization program that might apply.

Absence of a step therapy statement in this policy does not preclude plan-level step requirements.

Note

Verify benefit plan terms

Verify applicable federal, state, and contractual benefit plan terms before rendering or billing services. When plan terms conflict with this standard policy, the federal/state/contractual requirements govern coverage decisions.

Check the member's benefit contract and state-specific mandates prior to authorization or claim submission.
UnitedHealthcare may use InterQual® criteria or approved UnitedHealthcare Medical Policies when InterQual® is not applicable.

LimitationsMethods and devices are heterogeneous and evidence is insufficient to show consistent impact on patient management or outcomes.

Functional Lumen Imaging Probe (FLIP) — definition of FLIP

DefinitionA catheter‑based endoscopic system designed to assess esophageal motility and the distensibility index at the esophagogastric junction by measuring diameter and pressure during balloon distension.

Clinical roleDescribed as a complementary assessment of esophagogastric junction opening dynamics and esophageal wall stiffness; may be useful when standard manometry cannot be completed.

GuidanceGuidelines advise not to make diagnosis or treatment decisions based on FLIP alone; use within established protocols and disease‑specific analysis paradigms.

Magnetic Resonance Defecography — definition of MRD

DefinitionA noninvasive magnetic resonance imaging test that obtains images at various stages of defecation to evaluate pelvic floor anatomy, dynamic motion, and rectal evacuation.

Comparative roleCan provide soft‑tissue detail and dynamic assessment but is not established to replace evacuation proctography (EP) as the reference standard; sensitivity varies with inclusion of evacuation phase.

Clinical integrationShould be correlated with symptoms and other tests; use MRD when EP is inconclusive or additional soft‑tissue detail is required (triage or preoperative planning).

FLIP / EndoFLIP — alternate FLIP definition entries

Alternate nameOften referred to as EndoFLIP (EndoFLIP® System) — an endoluminal functional luminal imaging probe available since 2009.

Measurement capabilityMeasures simultaneous pressure and diameter to evaluate esophagogastric junction opening dynamics and esophageal wall stiffness.

Practice noteLimited penetration into general practice due to sparse data, lack of standardized protocols, and evolving role per professional guidance.

FLIP (EndoFLIP) — added definition entry

Definition updateFLIP definition has been added to the policy definitions to clarify the technology and its intended assessment of EGJ distensibility and compliance.

Policy changeFLIP technology was added to the list of unproven and not medically necessary procedures for diagnosing achalasia in the April 1, 2026 revision.

Clinical contextRecognized as a complementary tool; not recommended as sole basis for diagnosis or treatment decisions per AGA/ACG guidance.

MRI defecography (MRD) — additional MRD definition entry

Additional entryMR defecography is defined in policy as dynamic MRI performed during evacuation to assess pelvic floor anatomy and function; included to reflect evidence and guideline context.

Evidence noteCochrane/meta‑analysis and comparative studies report MRD sensitivity is higher when evacuation phase is included but MRD does not consistently outperform EP for all diagnoses.

Use considerationMRD may be used for triage or preoperative planning when EP is inconclusive; clinicians should correlate MRD with symptoms and other testing.

BSGM / Gastric Alimetry — definition of body surface gastric mapping

DefinitionBody surface gastric mapping (BSGM) is a noninvasive multichannel cutaneous mapping technique (for example, Gastric Alimetry) that records gastric myoelectrical activity and derives spectral and spatial biomarkers for phenotyping gastric dysfunction.

Potential roleBSGM may improve phenotyping of chronic gastroduodenal disorders and show stronger symptom correlations than traditional gastric emptying testing in small studies.

Evidence caveatPublished evidence (including ECRI assessment) is limited in quality and size; clinical utility for improving patient‑level outcomes is not established.

BSGM / Body Surface Gastric Mapping — high-resolution mapping definition

High‑resolution mappingHigh‑resolution body surface gastric mapping refers to noninvasive, multichannel, high‑resolution cutaneous recordings of gastric slow‑wave activity used to characterize gastric electrophysiology and phenotype gastroduodenal disorders.

Performance vs EGGIn multicenter comparisons, BSGM demonstrated tighter frequency precision, greater symptom correlations, and higher patient‑level classification accuracy than low‑resolution EGG.

LimitationsStudies are limited by heterogeneous protocols, small sample sizes, and need for standardized validation versus reference standards before routine clinical adoption.

EGG / Electrogastrography — low-resolution transcutaneous recording definition

Definition (low‑resolution)Electrogastrography (EGG) is a low‑resolution transcutaneous recording of gastric myoelectrical activity using cutaneous electrodes placed over the stomach.

Historical useHistorically used to detect gastric dysrhythmias and to study group‑level differences but limited by heterogeneous methods and weak symptom correlation in some studies.

Comparative noteEGG shows poorer patient‑level classification accuracy and fewer symptom correlations compared with BSGM in comparative studies.

MI / Mucosal Impedance Testing — definition and clinical role

DefinitionMucosal impedance (MI) testing measures esophageal epithelial impedance during endoscopy to assess mucosal integrity and help distinguish GERD, eosinophilic esophagitis (EoE), and non‑GERD patterns.

Clinical findingsTest‑validation studies report distinct MI patterns for GERD, EoE, and non‑GERD; MI may instantaneously detect mucosal integrity changes during EGD.

Evidence and regulatory noteMiVu MI system received FDA de novo Class II clearance, but clinical utility and impact on outcomes remain limited and require further validation.

Achalasia (added) — Achalasia definition added to policy definitions (new)

New definition addedAchalasia definition was added to the policy's definitions list clarifying it as a primary esophageal motor disorder with impaired EGJ relaxation and loss of organized peristalsis.

Policy contextAddition reflects the April 1, 2026 policy revision which included new and clarified definitions.

Relevance to FLIPAchalasia is a condition for which FLIP may be used adjunctively, but FLIP is listed in the policy as unproven/not medically necessary for diagnosing achalasia.

Device examples removed from unproven list

Specific examples of cutaneous, mucous, or serosal electrogastrography and body surface gastric mapping systems (including Gastric Alimetry System and G-Tech Gut Tracker) and the MiVu mucosal integrity testing system were removed from the unproven/not medically necessary list.

2026-04-01CPT codes removed

CPT codes 43647, 43648, 43881, 43882, 64590, and 64595 were removed from the applicable codes section.