ModifiedUnitedHealthcarePolicy CS046NM.D

Gastrointestinal Disorders Diagnostic Procedures (for New Mexico Only)

Defines UnitedHealthcare New Mexico coverage stance for selected diagnostic procedures used in evaluating gastrointestinal disorders (eg, constipation, fecal incontinence, gastroparesis, esophageal motility disorders) and who it affects (providers and members in New Mexico).

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Disorders Diagnostic Procedures (for New Mexico Only)

Policy CodePolicy CS046NM.D

Change TypeMaterial revisions to coverage lists, coding, and relocated content

Effective DateApr 1, 2026

Next Review Date

Key ActionWhen requesting MRI defecography or FLIP, document prior anorectal testing (ARM, BET) or rationale why standard testing could not be completed and verify current prior authorization and applicable code lists.

SourceLink

POLICY UPDATE CHANGES

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

Removed and relocated language pertaining to gastric electrical stimulation (GES) therapy to a different policy.

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

Several examples of electrogastrography/body surface gastric mapping systems and esophageal mucosal integrity testing (MiVu) were removed from the list.

Title changed from 'Gastrointestinal Motility Disorders, Diagnosis and Treatment (for New Mexico Only)' to the current title and coverage rationale was reorganized.

6CPT codes removed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

new procedure listed as unproven

NM onlystate applicability

12+CPT/HCPCS/unlisted codes referenced

Severalevidence summaries referenced

Coverage Criteria and Rationale

Unproven / Not Medically Necessary

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

Unproven / Not Medically Necessary Procedures: Magnetic Resonance Imaging (MRI) Defecography for evaluating Constipation and Anorectal or pelvic floor disorders; Cutaneous, mucous, or serosal Electrogastrography, 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.

These are listed explicitly as unproven and not medically necessary in the Coverage Rationale.

Use of FLIP

Summary stance from professional society guidance

FLIP/EndoFLIP: FLIP is a complementary diagnostic tool and should not be used alone to make diagnosis or treatment decisions; it may be useful when standard manometry cannot be completed and its role is evolving pending further study.

AGA and ACG guidance advise that FLIP assessments be used as an adjunct (not as standalone diagnostic) and that FLIP not be used routinely for GERD diagnosis; utilization should follow disease-specific protocols and analysis paradigms.

MRI defecography: indications and constraints

Evidence and guideline-informed stance on MRI defecography

MRD utility and constraints: MR defecography (MRD) can identify structural pelvic floor disorders and may aid multidisciplinary decision-making or preoperative planning, but technical success and sensitivity are lower than fluoroscopic/video defecography, particularly when an evacuation phase is not performed; MRD should be considered when anorectal manometry (ARM) and rectal balloon expulsion testing (BET) are inconclusive or when additional anatomic detail is required.

Systematic reviews and comparative studies report higher technical adequacy and detection rates with fluoroscopic defecography and improved MRD sensitivity when performed with an evacuation phase; professional guidelines recommend MRD when ARM/BET are equivocal or for additional anatomic assessment.

Electrogastrography and Body Surface Gastric Mapping

Evidence and stance on EGG and BSGM

EGG/BSGM evidence: Conventional transcutaneous electrogastrography (EGG) is experimental/limited for routine diagnosis because of heterogeneous methods and uncertain impact on patient management; body surface gastric mapping (BSGM, e.g., Gastric Alimetry) provides improved signal and phenotyping compared with EGG but current evidence quality is low and clinical utility—demonstrated improvement in patient-relevant outcomes—has not been established.

Systematic reviews and technology assessments (including ECRI) rate available evidence as low/very low and call for standardized protocols and clinical utility studies.

Coverage rationale for emerging diagnostic technologies

Coverage stance and evidence summary for EGG/BSGM and Esophageal Mucosal Integrity Testing

EGG/BSGM (coverage rationale): Although physiologic differences and patient phenotypes have been identified by EGG and BSGM in disorders such as GERD, functional dyspepsia, and gastroparesis, heterogeneity of methods and lack of evidence showing improved clinical outcomes limit current clinical application; use is considered investigational beyond research or adjunctive contexts.

Evidence includes cohort and small comparative studies and systematic reviews with limitations; ECRI rated Gastric Alimetry evidence very low.

Esophageal Mucosal Integrity Testing (MI): MI testing (eg, balloon mucosal impedance systems) demonstrates distinct impedance patterns among GERD, EoE, and non-GERD in small studies, but limited sample sizes, homogenous populations, and lack of independent validation or demonstrated clinical utility mean MI testing is investigational and not supported as a routine replacement for established diagnostics.

Hayes and ECRI evidence assessments and small prospective/retrospective studies report promising diagnostic patterns but insufficient evidence of impact on management or outcomes.

EndoFLIP (FLIP) is FDA-cleared as an adjunctive impedance planimetry tool to measure esophageal and pyloric dimensions and pressures; clinical use should be adjunctive within comprehensive evaluation and per device indications rather than as a standalone diagnostic replacement.

The procedures listed below are explicitly considered unproven and not medically necessary for the specified indications due to insufficient evidence of efficacy. These services are excluded from coverage for those indications: MRI Defecography for evaluation of constipation and anorectal/pelvic floor disorders; cutaneous, mucous, or serosal Electrogastrography (EGG), electroenterography, or Body Surface Gastric Mapping (BSGM) for diagnosing intestinal or gastric disorders including gastroparesis; Esophageal Mucosal Integrity (MI) Testing by electrical impedance for diagnosis of GERD, eosinophilic esophagitis (EoE), nonacid reflux, or for monitoring treatment response; and Functional Lumen Imaging Probe (FLIP) technology for diagnosing achalasia.

Professional society guidance characterizes FLIP/EndoFLIP as an adjunctive measurement tool rather than a standalone diagnostic test. The AGA recommends that clinicians not make a diagnosis or treatment decision based on FLIP assessment alone, that FLIP be used as a complementary assessment of esophagogastric junction opening dynamics and wall stiffness, and that it not be used routinely for GERD diagnosis. Documented use of FLIP should explain why standard manometry could not be completed when applicable and should follow distinct protocols and analysis paradigms for the disease state of interest.

The American College of Gastroenterology (ACG) states that mucosal integrity testing is commercially available but is not sufficiently developed to warrant discussion in current GERD guidelines. Published evidence is limited and does not yet support routine clinical use of MI testing as a preferred or standalone diagnostic method for GERD, EoE, or related conditions.

Per the policy revision, FLIP technology for diagnosing Achalasia has been added to the list of procedures considered unproven and not medically necessary. As a result, use of FLIP as the basis for diagnosing achalasia is excluded from coverage pending stronger evidence demonstrating diagnostic accuracy and meaningful impact on patient management.

Examples of procedures and techniques identified as excluded or limited by the evidence include MRI Defecography for routine evaluation of constipation and pelvic floor disorders, particularly when performed without an evacuation phase; and other advanced or emerging imaging or physiologic tests that lack demonstrated clinical utility. MRI defecography technical limitations (eg, lower sensitivity than fluoroscopic/video defecography and reduced diagnostic yield without evacuation) have been noted as reasons for concern when used as a substitute for standard testing.

Conventional transcutaneous Electrogastrography (EGG) and similar surface mapping methods are not supported as substitutes for established gastric emptying testing (eg, scintigraphy) for diagnosis of gastric stasis or gastroparesis. Systematic reviews and evidence assessments report heterogeneity in methods, limited diagnostic accuracy data, and insufficient evidence that EGG/BSGM use improves patient-relevant outcomes.

Overall, the policy considers EGG/BSGM and esophageal mucosal impedance testing (MI) as emerging technologies with limited, low-quality evidence. Current data do not support routine replacement of established diagnostic standards; these modalities are considered investigational or unproven outside of research or adjunctive contexts and lack demonstrated clinical utility to guide management decisions.

Reiterating the policy revision: FLIP for diagnosing achalasia is specifically listed among procedures judged to be unproven and not medically necessary. This listing reflects the panel's assessment that available evidence is insufficient to support FLIP as a primary diagnostic method for achalasia.

Applicable Codes and Code Changes

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.

Previously listed Applicable CPT Codes removedCPT

43647	Removed from Applicable Codes (no description provided in this section)
43648	Removed from Applicable Codes (no description provided in this section)
43881	Removed from Applicable Codes (no description provided in this section)
43882	Removed from Applicable Codes (no description provided in this section)
64590	Removed from Applicable Codes (no description provided in this section)
64595	Removed from Applicable Codes (no description provided in this section)

Removed CPT codesCPTNot Covered

43647	removed from Applicable Codes
43648	removed from Applicable Codes
43881	removed from Applicable Codes
43882	removed from Applicable Codes
64590	removed from Applicable Codes
64595	removed from Applicable Codes

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization and Coding Verification

Prior authorization may be required for procedures listed in this policy; services using codes that correspond to procedures deemed not medically necessary may be denied if prior authorization is not obtained or documentation does not support medical necessity.

Verify prior authorization requirements for current codes before scheduling or performing services.
Codes removed from the Applicable Codes list may still appear on claims — providers should confirm up-to-date billing requirements to avoid denials.

Prior Authorization

Prior Authorization for MR Defecography

MRI defecography requests should be justified by documentation that standard anorectal testing was inconclusive or could not be completed, or that additional anatomic detail is needed for management or surgical planning.

Document results of anorectal manometry (ARM) and rectal balloon expulsion test (BET) and why these were inconclusive or not feasible when ordering MR defecography.
MR defecography performed without an evacuation phase has substantially lower sensitivity; note whether an evacuation phase was included.

Clinical Background

Clinical conditions covered by this policy commonly require objective testing to identify and characterize underlying dysfunction. Disorders include constipation and defecatory/pelvic floor disorders where anorectal manometry, rectal balloon expulsion testing, and selective imaging are used; fecal incontinence that may require physiologic and anatomic assessment; gastroparesis and other gastric motility disorders where gastric emptying scintigraphy is the reference standard; and esophageal motility disorders such as achalasia where comprehensive evaluation typically includes manometry and radiographic studies. Emerging technologies described in this policy (eg, MRI defecography, EGG/BSGM, MI testing, FLIP) have evolving roles but currently lack sufficient evidence to replace validated, standardized diagnostic pathways.

Definitions

Achalasia — definition entry

TermAchalasia

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

Source noteDefinition added to policy during 04/01/2026 revision.

Electrogastrography (EGG) — definition entry

TermElectrogastrography (EGG)

DefinitionA noninvasive method to measure gastric myoelectrical activity using cutaneous electrodes placed on the abdominal skin over the stomach.

Clinical context

Policy Revision History

2026-04-01revisionLatest

Title changed from 'Gastrointestinal Motility Disorders, Diagnosis and Treatment (for New Mexico Only)' and coverage rationale reorganized; FLIP (Functional Lumen Imaging Probe) added to list of unproven/not medically necessary procedures; examples of certain EGG/BSGM systems and the MiVu mucosal integrity system were removed; definitions for Achalasia and FLIP were added; CPT codes 43647, 43648, 43881, 43882, 64590, and 64595 were removed from Applicable Codes; language regarding gastric electrical stimulation (GES) was removed and relocated to a related policy.

archival

Previous policy version CS046NM.C was archived and supporting sections (Description of Services, Clinical Evidence, FDA, References) were updated to reflect current information.

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Disorders Diagnostic Procedures (for New Mexico Only)

Policy CodePolicy CS046NM.D

Change TypeMaterial revisions to coverage lists, coding, and relocated content

Effective DateApr 1, 2026

Next Review Date

SourceLink

On This Page

FDA 510(k) clearance and society guidance support FLIP's adjunctive role; it should not be used alone to make diagnoses or treatment decisions.

Denial Risk

Denial Risk for MR Defecography and Unproven Indications

Requests for MR defecography for routine constipation or pelvic floor disorders without prior basic testing or without evacuation-phase imaging may be denied due to limited incremental benefit over standard testing.

Fluoroscopic (evacuation) defecography or clinical exam findings may be preferred; MRD is generally a triage/additional imaging test rather than a first-line replacement.

Documentation Required

FLIP — Complementary Use and Documentation Expectations

FLIP is a complementary tool and should not be used as a standalone diagnostic test. Prior authorization requests for FLIP should document why standard tests (eg, manometry, barium esophagram) were insufficient or contraindicated.

Document adherence to society guidance (AGA/ACG) that FLIP be used in conjunction with other diagnostic data.
State why conventional manometry could not be completed if FLIP is being used in its place.

Documentation Required

Stepwise Evaluation and Documentation Requirements

When requesting advanced imaging or procedures, document a stepwise evaluation showing that less invasive or standard diagnostic steps were performed or attempted prior to advanced testing.

For pelvic floor evaluation, document digital rectal exam, ARM, and BET results or attempts before MR defecography.
For esophageal evaluation, document EGD findings and correlation with other diagnostic data when using mucosal impedance or MI measurements during endoscopy.

Denial Risk

Denial Risk for Mucosal Impedance and Other Emerging Tests

Requests for esophageal mucosal impedance (MI) testing or other emerging/novel tests may be denied when used as sole diagnostic modalities due to limited validation and small sample sizes in the literature.

Include corroborating diagnostic data (EGD findings, pH monitoring, biopsies) when submitting MI test claims or prior authorization requests.
Clinical utility studies are limited; absence of supporting tests increases denial risk.

Step Therapy

No Step Therapy Specified

No specific step therapy is defined in this policy. Emerging technologies covered here are considered adjunctive and not replacements for established diagnostic workflows.

Follow established diagnostic algorithms and society guidelines when sequencing tests.

Documentation Required

Documentation Expectations and Protocol Adherence

Providers should include diagnostic rationale and show adherence to validated, standardized study protocols (for example, scintigraphy protocols for gastric emptying) when requesting coverage for gastrointestinal function testing.

For gastric emptying studies, document test meal consumption and imaging duration per recommended protocols.
For EGG/BSGM and other motility tests, include protocol adherence and interpretation rationale.

Documentation Required

Required Clinical Documentation for MR Defecography

When MR defecography is requested, include required clinical documentation demonstrating indication and prior anorectal testing; lack of this documentation may result in denial.

Specify whether MRD included static, dynamic, and evacuation-phase imaging.
Attach ARM and BET results or a narrative explaining why those tests were inconclusive or not performed.

Documentation Required

Required Documentation for FLIP

When FLIP is used, document why standard tests were insufficient or contraindicated and confirm FLIP is being used as a complementary assessment per society guidance rather than as a stand-alone diagnostic.

If FLIP performed during sedated endoscopy substituted for manometry, document the reason (eg, intolerance, technical failure).
Attach protocol and analysis paradigm used for FLIP testing.

Documentation Required

Document EGD and Corroborating Diagnostic Data for MI Testing

Document EGD findings and correlate mucosal impedance (MI) measurements with other diagnostic data when MI measurements are used to support a diagnosis; do not rely on MI alone.

Include biopsy results, pH monitoring, or other concordant tests where available.
Note that MI devices have limited evidence; include test validation details when available.

Billing Rule

Code List Changes and Prior Authorization Impact

Providers must verify current prior authorization and coding requirements following removal or changes to the policy's Applicable Codes list to avoid claim denials.

Codes removed from the Applicable Codes section of this policy (per revision history) may affect billing — confirm payer-specific code requirements.
Contact UnitedHealthcare prior authorization services or use the payer's provider portal for up-to-date code and authorization guidance.

Note

Plan-Specific Contractual Requirements Govern Coverage

Reference federal, state, and contractual benefit plan requirements when making coverage determination as these govern over this standard medical policy in the event of conflict.

Before relying solely on this policy, verify any plan-specific coverage mandates or exclusions.

Note

Provider Action Placeholder

Placeholder: Additional provider actions or state-specific requirements may be added; monitor policy updates and payer communications for any new submission requirements.

Considered investigational/limited utility for routine diagnosis of gastric stasis or gastroparesis; evidence is heterogeneous and lacks demonstrated impact on patient outcomes.

Magnetic Resonance Defecography — definition entry

TermMagnetic Resonance Defecography

DefinitionA noninvasive MRI-based test that obtains images at various stages of defecation to evaluate pelvic floor anatomy, dynamic motion, and rectal evacuation.

LimitationsEvidence is insufficient to demonstrate superiority to conventional defecography; sensitivity is reduced without an evacuation phase and technical success may be lower than fluoroscopic methods.

Functional Lumen Imaging Probe (FLIP) — definition entry

TermFunctional Lumen Imaging Probe (FLIP)

DefinitionA catheter-based endoscopic system that measures lumen diameter and distensibility (distensibility index) to assess esophageal or esophagogastric junction compliance by simultaneous pressure and diameter measurements.

Clinical useEndoscopic adjunct used to assess EGJ opening dynamics and esophageal wall stiffness; recommended as complementary, not standalone, for diagnosis or treatment decisions.

FLIP / EndoFLIP — definition entry (related term)

TermFLIP / EndoFLIP

DefinitionEndoscopic impedance planimetry system (FLIP/EndoFLIP) that measures simultaneous pressure and diameter to assess esophagogastric junction opening dynamics and esophageal wall stiffness; EndoFLIP has FDA 510(k) clearance and is intended as an adjunctive tool.

GuidanceAGA and other societies state FLIP should not be used alone to make diagnoses or treatment decisions and should follow disease-specific protocols.

MRI defecography (MRD) — definition entry (alternate term)

TermMRI defecography (MRD)

DefinitionDynamic magnetic resonance imaging of defecation used to evaluate pelvic floor anatomy and function, typically including static and dynamic sequences and an evacuation phase.

Usage noteShould be considered when anorectal manometry and rectal balloon expulsion testing are inconclusive or when additional anatomic detail is required for planning.

BSGM / Gastric Alimetry — definition entry

TermBSGM / Gastric Alimetry

DefinitionBody Surface Gastric Mapping (BSGM), exemplified by Gastric Alimetry, is a noninvasive high-resolution surface mapping technique that records gastric myoelectrical activity to identify rhythm abnormalities and phenotypes in gastroduodenal disorders.

Evidence summaryEmerging technology with improved signal/phenotyping versus conventional EGG but current evidence quality is low and lacks demonstrated improvement in patient-relevant outcomes.

MiVu MI System — definition entry including FDA de novo clearance note

TermMiVu MI System

DefinitionMiVu Mucosal Integrity Testing System: a device to measure esophageal epithelial impedance during endoscopy.

Regulatory noteReceived FDA de novo Class II clearance on December 23, 2019 and subsequent 510(k) clearance (K230056) on April 25, 2023.

EndoFLIP — definition entry including FDA 510(k) approval note

TermEndoFLIP

DefinitionAn impedance planimetry system indicated to measure pressure and dimensions in the esophagus, pylorus, and anal sphincters; intended as an adjunct in comprehensive motility evaluations.

Regulatory noteReceived FDA 510(k) approval on April 17, 2017.

Achalasia; Functional Lumen Imaging Probe (FLIP) — definitions added note

NoteDefinitions for Achalasia and Functional Lumen Imaging Probe (FLIP) were added to the policy in the 04/01/2026 revision.

ScopeAddition reflects policy update that also listed FLIP for diagnosing Achalasia among procedures considered unproven and not medically necessary.

ReferenceSee Policy History/Revision Information (04/01/2026).