ModifiedUnitedHealthcarePolicy CS046KS.03

Gastrointestinal Disorders Diagnostic Procedures (for Kansas Only)

This Kansas-only UnitedHealthcare medical policy governs coverage determinations for selected diagnostic procedures used to evaluate gastrointestinal motility, pelvic floor/anorectal disorders, and related esophageal and gastric functional testing; it applies to providers and members in the state of Kansas.

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Disorders Diagnostic Procedures (for Kansas Only)

Policy CodePolicy CS046KS.03

Change TypeTitle revisioncontent edits adding FLIP to unproven list and relocating GES language

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionDocument and submit prior anorectal manometry (ARM) and balloon expulsion test (BET) results when requesting MRI defecography authorization.

SourceLink

POLICY UPDATE CHANGES

Title changed from 'Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Kansas Only)' to current title and language regarding gastric electrical stimulation (GES) therapy was removed and relocated to a different medical policy.

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 System were removed from the list.

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

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

severalunproven procedures

Kansasjurisdiction

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39pelvic floor imaging studies

Coverage Criteria and Policy Rationale

Not Medically Necessary / Unproven

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

Unproven procedures (Not Medically Necessary): Magnetic Resonance Imaging (MRI) Defecography for evaluation of 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 GERD, eosinophilic esophagitis (EoE), and nonacid reflux disease or for monitoring treatment response in GERD and EoE; Functional Lumen Imaging Probe (FLIP) technology for diagnosing achalasia.

Determination based on insufficient high-quality evidence cited in the policy.

FLIP / EndoFLIP

Coverage approach based on available evidence and guideline recommendations in this section:

FLIP (EndoFLIP) — complementary use: FLIP may be used as a complementary assessment of esophagogastric junction opening dynamics and esophageal wall stiffness (for example when standard manometry cannot be tolerated or completed) but should not be used alone to make diagnostic or treatment decisions; the role of FLIP is evolving and additional high-quality studies are needed to define impact on patient-centered outcomes.

Reflects ACG/AGA guidance and multiple evidence reviews noting insufficient evidence to replace standard diagnostics.

MRI Defecography

Use of MRI defecography in pelvic floor disorders:

Role of MRI defecography (MRD): MR defecography may be used when anorectal manometry (ARM) and balloon expulsion testing (BET) are inconclusive or when additional soft-tissue anatomic detail is needed for preoperative planning; MRD does not replace evacuation proctography (EP) as the reference standard and has variable technical success and sensitivity depending on inclusion of an evacuation phase.

Based on systematic reviews, comparative studies, and society guideline recommendations advising stepwise evaluation (clinical exam → ARM/BET → defecography if equivocal).

Electrogastrography / BSGM

Coverage stance for electrogastrography and BSGM:

EGG/BSGM investigational status: Conventional cutaneous electrogastrography (EGG) lacks sufficient evidence of clinical utility; emerging high-resolution body surface gastric mapping (BSGM) demonstrates improved diagnostic correlations and patient-level classification versus traditional EGG in observational studies but lacks evidence that use of BSGM improves patient-relevant outcomes; further larger validation and clinical utility studies are needed.

Reflects systematic reviews, ECRI and Hayes assessments, and comparative cohort studies.

Evidence summary and limitations

Summary of evidence and typical clinical roles

BSGM vs EGG evidence: BSGM studies report improved frequency precision, stronger symptom correlations, and higher patient-level classification accuracy compared with traditional low-resolution EGG, but available studies are observational, have small samples, heterogeneous methods, and may use proprietary processing; clinical utility in improving outcomes is unproven.

Supported by Schamberg et al. 2023, Gharibans et al. 2022, and assessments noting methodological limitations.

EGG evidence: Low-resolution EGG shows some group-level differences across disorders (e.g., gastroparesis, GERD, functional dyspepsia) but inconsistent symptom correlations and generally low patient-level diagnostic accuracy; standardized recording and interpretation protocols and outcome studies are lacking.

Supported by Peralta-Palmezano et al. 2024, Bhat et al. 2021, Russo 2017.

Esophageal mucosal integrity (MI) evidence: Balloon or catheter-based MI measured during endoscopy can distinguish patterns seen in GERD, EoE, and non-GERD in limited studies, but sample sizes are small, populations are homogeneous, blinding and prospective validation are limited, and there is insufficient evidence that MI testing alone changes patient management or outcomes.

Procedures explicitly listed as unproven in this policy are excluded from medical necessity coverage. Examples of technologies designated as unproven and not medically necessary are provided in the Coverage Rationale and include imaging and physiologic tests for which current evidence is insufficient to demonstrate clinical benefit.

The Functional Lumen Imaging Probe (FLIP/EndoFLIP) may be used as a complementary tool in select settings, but clinicians should not make a diagnosis or treatment decision based on FLIP assessment alone. Professional guidance notes limited penetrance outside specialized centers, lack of standardized protocols and analysis methods, and specifically states that FLIP should not be used in routine diagnostic evaluations of GERD.

Esophageal mucosal impedance (MI) testing is not recommended as a standalone screening diagnostic. Evidence reviews conclude published studies are limited in size and quality, and professional guidelines do not endorse MI or related emerging tests as a preferred primary diagnostic in place of standard evaluations; MI has been described as developing technology that may have adjunctive roles but lacks demonstrated clinical utility as a sole diagnostic.

Language regarding gastric electrical stimulation (GES) therapy was removed from this policy and relocated to a separate UnitedHealthcare medical policy titled "Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Kansas Only)."

Examples of procedures listed as unproven and therefore not medically necessary include: MRI Defecography for evaluation of constipation and anorectal or pelvic floor disorders, and cutaneous/mucous/serosal electrogastrography or body surface gastric mapping and other EGG variants for diagnosing gastric disorders such as gastroparesis or intestinal dysmotility.

MRI defecography should not be used as a substitute for fluoroscopic evacuation proctography (EP) when EP is the indicated reference standard; systematic reviews and comparative studies do not support MRD as a replacement. Similarly, electrogastrography (including Alimetry/BSGM variants) and related surface or cutaneous EGG techniques have limited evidence of clinical utility and lack demonstrated impact on patient-relevant outcomes.

Esophageal mucosal integrity testing by electrical impedance should not be used as the sole diagnostic test without corroborating standard diagnostics (for example, EGD, pH monitoring, and biopsies). Evidence assessments have concluded the technology is not validated sufficiently for standalone use and additional clinical validation and utility studies are needed.

Functional Lumen Imaging Probe (FLIP) technology is listed among procedures considered unproven and not medically necessary for diagnosing Achalasia in this policy update. While FLIP can measure esophagogastric junction distensibility and wall stiffness, professional guidance emphasizes it is complementary and should not be the sole basis for diagnosis.

Procedure and Device Codes (Reference Only)

Referenced procedure 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

Device product codes (FDA)mixed

MYE	FDA product code for cutaneous electrogastrography/electroenterography devices
FFX	FDA product code referenced for colonic transit markers and related devices

MiVu MI device product codemixed

QIS	FDA product code for MiVu Mucosal Integrity Testing System

Removed CPT CodesCPT

43647
43648
43881
43882
64590
64595

Provider Actions, Prior Authorization and Documentation

Note

Codes provided — prior authorization/benefit subject to contract

Codes listed in this policy are provided for reference and do not guarantee coverage. Prior authorization requirements and benefit coverage are subject to the member's federal, state, or contractual plan terms. Verify benefit coverage and prior authorization requirements with the member's plan before performing services.

Codes provided are informational only (e.g., 0779T, 0868T, 43499, 72195-72197, 76498, 91132-91133).
Listing of a code does not imply service is covered or payable.

Denial Risk

Evidence-based denial risk

Some procedures and imaging approaches in this policy are considered unproven or not medically necessary based on current evidence. Claims for services identified as not medically necessary may be denied. Use the Coverage Rationale and Evidence sections to evaluate denial risk.

MRI defecography for constipation and pelvic floor disorders is listed as unproven/not medically necessary and may be denied when submitted as a replacement for established testing.

Clinical Background and Scope

Constipation, fecal incontinence, and gastroparesis are common gastrointestinal disorders that frequently require objective testing to determine underlying motility or structural causes. Appropriate reference tests (for example, scintigraphic gastric emptying for gastroparesis and anorectal physiologic testing for pelvic floor disorders) remain central to diagnosis; emerging technologies are under study but generally lack sufficient evidence to replace established diagnostic standards.

Definitions and Terminology

Achalasia — definition (inv-35: 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 in the esophageal body.

Electrogastrography (EGG) — definition (inv-36: Electrogastrography (EGG))

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

Functional Lumen Imaging Probe (FLIP) — definition (inv-37: Functional Lumen Imaging Probe (FLIP))

DefinitionA catheter-based endoscopic system performed during endoscopy that assesses esophageal motility and the distensibility index at the esophagogastric junction by measuring diameter and pressure during balloon distension.

Policy Update Summary

2026-04-01title_change_and_relocationLatest

Policy title changed from 'Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Kansas Only)' and language regarding gastric electrical stimulation (GES) therapy was removed and relocated to a separate medical policy ('Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Kansas Only)').

2026-04-01added_unproven_procedure

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

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Disorders Diagnostic Procedures (for Kansas Only)

Policy CodePolicy CS046KS.03

Change TypeTitle revisioncontent edits adding FLIP to unproven list and relocating GES language

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionDocument and submit prior anorectal manometry (ARM) and balloon expulsion test (BET) results when requesting MRI defecography authorization.

SourceLink

On This Page

Supported by Patel 2019, Choksi 2018, Hayes 2022/2024, and ECRI 2021.

Esophageal mucosal integrity testing by electrical impedance has limited evidence; coverage may be denied as insufficiently supported.

Note

Benefit contract precedence

Federal, state, and contractual benefit requirements take precedence over this medical policy. In the event of a conflict, follow the applicable statutory or contract terms when determining coverage and prior authorization.

Check member-specific plan documents and regulatory requirements before relying on this policy for coverage decisions.
When applicable law or a benefit contract requires coverage contrary to this policy, that law or contract governs.

Documentation Required

Document clinical indication and rationale

Document the clinical indication and rationale on the prior authorization request and medical record. Include presenting symptoms, diagnostic uncertainty, and why the requested test is expected to inform management.

Record symptoms (e.g., obstructed defecation, fecal incontinence, suspected gastroparesis) and duration.
State why prior testing was inconclusive and how the requested study will change management.

Documentation Required

Required supporting documentation

When advanced pelvic floor imaging (e.g., MRI defecography or alternative MR studies) is requested, provide prior test results and supporting documentation. Failure to include required documentation may delay or result in denial of authorization.

Include results of anorectal manometry (ARM) and balloon expulsion test (BET) when MR defecography or equivalent imaging is requested.
If ARM/BET are not performed, document clinical reasons and prior management steps that justify imaging.
For mucosal impedance testing, document that measurements were performed during EGD and include corroborating tests (endoscopy findings, pH testing, biopsies) as applicable.

Note

Policy use and documentation

This policy is a guide to UnitedHealthcare standard benefits and may be updated. Verify InterQual criteria and member-specific benefit terms before approving or performing services.

UnitedHealthcare uses InterQual for primary decision support; when InterQual lacks criteria, UnitedHealthcare medical policies approved by the state may be used.
Providers should check for plan-specific prior authorization processes and submit complete documentation to avoid delays.
UnitedHealthcare may modify policies; do not treat this document as medical advice.

Step Therapy

Stepwise evaluation prior to imaging

Follow a stepwise diagnostic approach for evaluation of defecatory disorders: begin with clinical examination and basic physiologic testing; reserve advanced imaging for equivocal or inconclusive results.

Initial evaluation: focused clinical exam and history.
Physiologic testing: anorectal manometry (ARM) and balloon expulsion test (BET).
Advanced imaging (fluoroscopic defecography or MR defecography) only when ARM/BET are inconclusive or when structural abnormalities are suspected and imaging will affect management.

Note

Adjunctive use expectation

Adjunctive or emerging tests (e.g., mucosal impedance testing) are generally considered adjuncts to standard diagnostic pathways and should not replace established tests. Document how adjunctive testing complements standard evaluation.

Mucosal impedance testing is often adjunctive to EGD and should be accompanied by traditional diagnostic testing (endoscopy, pH monitoring, biopsies) as clinically indicated.
If using adjunctive testing to avoid more invasive or prolonged testing, provide clear documentation showing how the results will change patient management.

Magnetic Resonance Defecography — definition (inv-38: Magnetic Resonance Defecography)

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

FLIP (duplicate definition entry) — endolumenal device measuring pressure and diameter (inv-39: FLIP (duplicate definition entry))

Device descriptionAn endolumenal device (EndoFLIP) that measures simultaneous pressure and diameter to assess esophagogastric junction opening dynamics and esophageal wall stiffness during endoscopy.

MRI defecography (MRD) — definition (inv-40: MRI defecography (MRD))

DefinitionDynamic MRI imaging performed to evaluate pelvic floor structures and defecatory mechanics; can provide soft-tissue anatomic detail but does not replace evacuation proctography as the reference standard.

BSGM (Body Surface Gastric Mapping) — definition (inv-41: BSGM (Body Surface Gastric Mapping))

DefinitionA noninvasive technique (also called Gastric Alimetry in some studies) that records gastric myoelectrical activity from the abdominal surface to phenotype gastric motility and correlate with symptoms.

Body Surface Gastric Mapping (BSGM) — high-resolution mapping definition (inv-42: Body Surface Gastric Mapping (BSGM))

DefinitionHigh-resolution, multi-electrode, noninvasive mapping of gastric electrical activity from the body surface intended to provide spectral and spatial biomarkers for phenotyping gastric dysfunction.

Mucosal Impedance (MI) testing — definition (inv-43: Mucosal Impedance (MI) testing)

DefinitionMeasurement of esophageal epithelial electrical impedance during endoscopy using a balloon or catheter to assess mucosal integrity and help distinguish GERD, EoE, and non-GERD patterns.

Achalasia (definition added in latest version) (inv-44: Achalasia)

Policy additionDefinition of Achalasia was added to the policy: a primary esophageal motor disorder with impaired EGJ relaxation and loss of organized peristalsis due to myenteric plexus degeneration.

Functional Lumen Imaging Probe (FLIP) (definition added in latest version) (inv-45: Functional Lumen Imaging Probe (FLIP))

Policy additionDefinition of Functional Lumen Imaging Probe (FLIP) was added to the policy: a catheter-based endoscopic system that assesses esophageal motility and distensibility by measuring diameter and pressure during balloon distension; EndoFLIP measures simultaneous pressure and diameter but should not be used alone for diagnosis or treatment decisions.

removed_examples_and_device_names

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 list of unproven/not medically necessary procedures.

2026-04-01removed_cpt_codes

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

2026-04-01added_definitions

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

2026-04-01supporting_information_updated

Description of Services, Clinical Evidence, FDA, and References sections were updated and the previous policy version CS046KS.02 was archived.

This policy applies only to providers and members in the state of Kansas. The current version includes material changes effective 04/01/2026 including a title change and relocation of gastric electrical stimulation language to a separate policy. The policy also added FLIP for diagnosing Achalasia to the list of unproven/not medically necessary procedures; removed specific device examples and several CPT codes from the applicable codes section. Providers should confirm benefit applicability per federal, state, or contract terms.