ModifiedUnitedHealthcarePolicy CSNCT0415.03

Gastrointestinal Disorders Diagnostic Procedures (for North Carolina Only)

Defines UnitedHealthcare medical policy for diagnostic procedures related to gastrointestinal disorders (North Carolina only), including coverage stance for specific tests and documentation requirements affecting providers and members in NC.

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Disorders Diagnostic Procedures (for North Carolina Only)

Policy CodePolicy CSNCT0415.03

Change TypeRevision with material coverage updates

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionEnsure medical records fully document clinical history, exam, and prior diagnostic test results to support medical necessity when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Title changed from 'Gastrointestinal Motility Disorders, Diagnosis and Treatment (for North Carolina Only)' and coverage rationale reorganized 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.

Examples listing cutaneous, mucous, or serosal electrogastrography, electroenterography, or body surface gastric mapping (including Gastric Alimetry System and G-Tech Gut Tracker) were removed from the unproven/not medically necessary list.

Clarified medical record documentation requirements: record must fully support medical necessity and include relevant history, exam, and test results; documentation must be legible and available upon request.

Removed CPT codes 43647, 43648, 43881, 43882, 64590, and 64595 from the applicable codes list.

Noted that CPT codes 0779T, 0868T, 43499, 76498, 91132, and 91133 are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by NC Medicaid.

05/01/2026Effective date

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.

4+Unproven procedures

6Codes not on NC Medicaid

Coverage Rationale and Medical Necessity

Evidence summaries and guideline positions

ALL of the following

Electrogastrography (EGG), electroenterography, and body surface gastric mapping (BSGM): Multiple studies and systematic reviews show low-quality and heterogeneous evidence. Schamberg et al. (2023) found BSGM outperformed low-resolution EGG for symptom correlations and patient-level classification, but limitations included heterogeneous EGG processing and small samples. Gharibans et al. (2022) and Bhat et al. (2021) report potential diagnostic signals but are limited by small sample sizes, variable methods, and lack of demonstrated impact on patient-important outcomes. ECRI (2024) and other evidence assessments concluded evidence is very low quality and that clinical utility (improvement in outcomes) has not been demonstrated. Additional larger, standardized clinical validity and clinical utility studies are needed.
EGG/BSGM evidence synthesis
Magnetic Resonance Imaging (MRI) Defecography: A 2021 Cochrane review (van Gruting et al.) synthesizing 39 studies found MRI defecography has high specificity for rectocele, enterocele and intussusception but variable sensitivity relative to evacuation proctography (EP). MRI with evacuation phase performed better than without; overall, MRI and transperineal ultrasound (TPUS) did not meet criteria to replace EP as the reference standard but may serve as useful triage tests. Professional society guidance (AGA, ASCRS, ACG) states defecography (commonly fluoroscopic/EP) is useful when anorectal testing is inconclusive and that MRI defecography can assist in evaluation but does not replace seated evacuation proctography as the construct-valid evacuation examination.
MRI defecography evidence synthesis
Esophageal mucosal integrity testing (electrical impedance-based MI): Evidence consists mainly of small prospective and retrospective studies and limited evidence reviews (ECRI 2021; Hayes 2022, updated 2024). Patel et al. (2019) and Choksi et al. (2018) reported that balloon or catheter-based MI measurements can differentiate GERD, EoE and non-GERD phenotypes in study cohorts, but studies are limited by small sample sizes, single-center designs, potential measurement variability, and lack of demonstrated effect on clinical management or long-term outcomes. Hayes and ECRI conclude the evidence is insufficient to support routine diagnostic use and recommend further clinical validity and utility studies.
Mucosal integrity testing evidence synthesis
Functional Lumen Imaging Probe (FLIP): The ACG and AGA guidance acknowledge FLIP as a complementary tool for assessing esophagogastric junction dynamics and esophageal wall stiffness but caution that FLIP should not be used alone to make diagnostic or treatment decisions. The ACG notes FLIP’s role in achalasia is evolving and may be useful when standard manometry cannot be completed, but data are low-quality and further study is required to determine whether FLIP can replace or reduce manometry and barium studies. The AGA advises FLIP should not be used for routine GERD diagnosis and should not be the sole basis for diagnosis or treatment decisions.
FLIP guideline position

Applicable Codes and Coding Notes

Listed procedure codes (reference)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.
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

Removed from Applicable CodesCPT

43647	CPT code removed from applicable codes list
43648	CPT code removed from applicable codes list
43881	CPT code removed from applicable codes list
43882	CPT code removed from applicable codes list
64590	CPT code removed from applicable codes list
64595	CPT code removed from applicable codes list

Codes Not on NC Medicaid Fee ScheduleCPT

0779T	Not on NC Medicaid Fee Schedule; may not be covered
0868T	Not on NC Medicaid Fee Schedule; may not be covered
43499	Not on NC Medicaid Fee Schedule; may not be covered
76498	Not on NC Medicaid Fee Schedule; may not be covered
91132	Not on NC Medicaid Fee Schedule; may not be covered
91133	Not on NC Medicaid Fee Schedule; may not be covered

Coding — additional coding

Applicable procedure codes (reference)0779T, 0868T, 43499, 72195, 72196, 72197, 76498, 91132, 91133 (listed in policy's applicable codes section for reference)

Codes removed from applicable codes list43647, 43648, 43881, 43882, 64590, 64595 (removed per policy revision)

Codes not on NC Medicaid Fee Schedule0779T, 0868T, 43499, 76498, 91132, 91133 (may not be covered by NC Medicaid)

Provider Requirements, Documentation, and Billing Guidance

Billing Rule

Applicable Procedure and Diagnosis Codes (reference only)

The following list of procedure and diagnosis codes is provided for reference only and inclusion does not imply coverage or guarantee payment. Codes may be subject to state fee schedule restrictions.

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 - MRI pelvis without contrast
72196 - MRI pelvis with contrast
72197 - MRI pelvis without followed by with contrast and further sequences
76498 - Unlisted magnetic resonance procedure
91132 - Electrogastrography, diagnostic, transcutaneous
91133 - Electrogastrography, diagnostic, transcutaneous; with provocative testing

Clinical Background and Scope

Constipation, fecal incontinence, and gastroparesis are common gastrointestinal disorders that frequently require objective diagnostic testing to establish pathophysiology and guide management. Standard reference tests—such as anorectal manometry and balloon expulsion testing for defecatory disorders, and scintigraphic gastric emptying studies for suspected gastroparesis—remain the accepted diagnostic standards; emerging modalities may be useful adjuncts but currently lack sufficient evidence to replace these established tests.

Definitions and Device Descriptions

Achalasia — definition and key features

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

Key clinical featureImpaired EGJ relaxation with absent or disordered esophageal peristalsis.

Etiology noteDegeneration of the myenteric plexus is the underlying pathophysiology.

Related assessmentsEsophageal motility testing (manometry) and adjunctive tools such as FLIP may assess EGJ opening dynamics but should not be used alone for diagnosis.

Electrogastrography (EGG) — definition

Definition

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Disorders Diagnostic Procedures (for North Carolina Only)

Policy CodePolicy CSNCT0415.03

Change TypeRevision with material coverage updates

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionEnsure medical records fully document clinical history, exam, and prior diagnostic test results to support medical necessity when requesting coverage.

SourceLink

On This Page

*Codes marked with an asterisk are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.

Documentation Required

MRI Defecography — Prior Testing and Required Documentation

When MRI defecography (MRD) is considered, document prior diagnostic testing and results demonstrating incomplete or inconclusive evaluation with standard anorectal testing. Evidence and society guidance support MRD primarily when ARM (anorectal manometry), balloon expulsion test (BET), or fluoroscopic/video defecography are inconclusive or inadequate for surgical planning. Include in the record: history of symptoms, results and dates of ARM and BET, reason those tests were nondiagnostic or not tolerated, prior imaging reports (e.g., fluoroscopic defecography), and trial(s) of conservative management.

Document ARM and BET results and dates
If manometry could not be completed, note why (intolerance, technical failure) and whether FLIP was used as a complementary assessment during endoscopy
If prior fluoroscopic/video defecography was performed, include report and indication for MRD (e.g., preoperative planning or inconclusive prior study)
Document conservative therapy attempts (diet, fiber, laxatives) and duration before advanced imaging

Prior Authorization

NC Medicaid Coverage / Prior Authorization Note

North Carolina Medicaid considerations: codes labeled with an asterisk in the applicable codes list are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by NC Medicaid. Providers must verify state-specific coverage and prior authorization requirements before scheduling services for NC Medicaid members.

Codes not on NC Medicaid Fee Schedule: 0779T, 0868T, 43499, 76498, 91132, 91133

Denial Risk

Risk of Denial Due to Lower Diagnostic Yield (MRI Defecography)

Some imaging modalities have lower technical success or diagnostic yield compared with alternatives; this may increase the risk of claim denial or request for additional documentation. For example, MR defecography has demonstrated lower technical success rates and may be less diagnostic than video/fluoroscopic defecography in some series.

MR defecography technical success reported lower (e.g., ~45% fully diagnostic) compared with video defecography (~97%) in some studies — document justification when choosing MRD
If MRD is requested after an initial imaging test, include rationale why video/fluoroscopic defecography is not appropriate or sufficient for the clinical question

Denial Risk

Risk of Denial for EGG/BSGM When Used as Sole Diagnostic Basis

Electrogastrography (EGG) and body surface gastric mapping (BSGM) have limited, low-quality evidence when used as the sole basis for diagnosis or management decisions. Using these tests alone to justify interventions or changes in therapy may not be supported and can result in denial.

EGG/BSGM should not be the sole diagnostic basis for gastroparesis or gastric stasis treatment decisions
Provide concurrent standard testing (e.g., gastric emptying scintigraphy) and clinical correlation if EGG/BSGM is submitted for review
Document why standard testing was not feasible if EGG/BSGM is relied upon

Documentation Required

Esophageal Mucosal Integrity Testing — Limited Evidence and Documentation Expectations

Esophageal mucosal integrity (MI) testing (electrical impedance including MiVu) is evolving and currently has limited clinical evidence for routine use. Society statements and technology assessments advise that MI testing should be considered adjunctive; it should not replace standard diagnostic methods without clear supporting documentation.

Do not rely on MI testing alone to diagnose GERD, EoE, or non-GERD
If MI testing is performed during EGD, document the procedure details, indication, and any adverse events
Include comparison to standard tests (pH testing, biopsies, EGD findings) and state how MI results will change management

Step Therapy

Stepwise Evaluation Before Advanced Imaging — Pre-Imaging Diagnostic Workup

Before ordering advanced imaging for anorectal or pelvic floor disorders, ensure a stepwise diagnostic approach has been followed. Conservative measures and anorectal physiologic testing should be attempted and documented first; advanced imaging is generally appropriate when these initial evaluations are inconclusive or insufficient for management.

Confirm documented trials of conservative therapy (dietary measures, fiber, osmotic laxatives)
Confirm anorectal physiologic testing completed (ARM, BET) with results and interpretation
If ARM or BET were not completed or inconclusive, document reasons and any complementary testing (e.g., FLIP)
State the specific clinical question advanced imaging will address (e.g., preoperative anatomy, suspected enterocele not seen on exam)

A non-invasive method for measuring gastric myoelectrical activity using cutaneous electrodes placed on the abdominal skin over the stomach.

Typical useInvestigational adjunct to characterize gastric rhythm abnormalities; not established to replace gastric emptying scintigraphy.

LimitationsHeterogeneous methods, low-resolution with variable symptom correlation; evidence for clinical utility is limited.

Magnetic Resonance Defecography — definition

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

Clinical roleCan identify structural causes of outlet obstruction and may be useful when anorectal testing (ARM/BET) is inconclusive or for preoperative planning.

Comparative evidenceMeta-analysis indicates MRD does not replace evacuation proctography (EP) as the reference standard; evacuation-phase MRD has higher sensitivity than MRD without evacuation.

Functional Lumen Imaging Probe (FLIP) — definition

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 useUsed as a complementary assessment of EGJ opening dynamics and esophageal wall stiffness, particularly when manometry cannot be completed or tolerated.

Diagnostic cautionShould not be used alone to make a diagnosis or treatment decision; utilization should follow standardized protocols and analysis paradigms.

FLIP / EndoFLIP — device context and FDA status

Device contextFLIP (EndoFLIP) is an endolumenal functional lumen imaging probe used to measure simultaneous pressure and diameter to assess EGJ opening dynamics and esophageal wall stiffness.

FDA statusDescribed in AGA guidance as a Food and Drug Administration–approved measurement tool (EndoFLIP available since 2009).

Practice implicationLimited penetrance outside specialized centers due to paucity of data, lack of standardized protocols, and evolving role in esophageal disorders.

MRI defecography (MRD) — definition and technique

DefinitionDynamic magnetic resonance imaging technique performed with or without an evacuation phase to evaluate pelvic floor anatomy and defecation dynamics.

Technique notePerforming MRD with an evacuation phase increases sensitivity for detecting rectocele and enterocele compared with MRD without evacuation.

LimitationsMRD does not meet criteria to replace evacuation proctography (EP) as the diagnostic reference standard per systematic review; more studies recommended.

BSGM / EGG — definition and limitations

DefinitionCollective term for noninvasive surface recordings of gastric myoelectrical activity, including low-resolution transcutaneous EGG and higher-resolution multichannel Body Surface Gastric Mapping (BSGM).

Performance notesBSGM shows improved frequency stability, symptom correlations, and patient-level classification accuracy versus traditional EGG in comparative studies, but limitations include heterogeneous methods and small sample sizes.

Evidence qualityOverall evidence judged low to very low; clinical utility and outcome benefit not yet established—additional validation and clinical utility studies needed.

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

DefinitionHigh-resolution, multi-electrode, noninvasive mapping of gastric myoelectrical activity intended to detect rhythm abnormalities and correlate findings with symptoms (example: Gastric Alimetry system in studies).

Study findingsComparative studies report tighter frequency ranges, more symptom correlations, and higher patient-level classification accuracy for BSGM versus EGG.

Current statusPromising for phenotyping but requires larger clinical validity and clinical utility studies before routine diagnostic use is established.

Electrogastrography (EGG) — transcutaneous recording definition

DefinitionTranscutaneous recording of gastric electrical activity using cutaneous electrodes placed over the stomach; typically low-resolution and heterogenous in methodology.

Utility concernsStudies show variable symptom correlation and limited accuracy for patient-level classification compared with high-resolution BSGM.

Research roleCurrent use primarily investigational or research; not established as a standalone replacement for gastric emptying scintigraphy.

Mucosal Impedance (MI) Testing — definition and measurement context

DefinitionMeasurement of esophageal epithelial (mucosal) impedance during endoscopy using balloon or catheter-based sensors to assess mucosal integrity.

Intended purposeProposed to help distinguish GERD from eosinophilic esophagitis (EoE) and non-GERD and potentially reduce need for prolonged pH monitoring or biopsies.

Safety and evidenceStudies report promising diagnostic patterns but evidence is limited and clinical utility not yet established; one study reported a small mucosal tear adverse event during EGD with MI measurement.

FLIP — functional lumen imaging probe (alternate entry)

DefinitionFunctional Lumen Imaging Probe (FLIP) technology: an endolumenal, catheter-based system that measures simultaneous diameter and pressure to assess esophagogastric junction opening dynamics and esophageal wall stiffness during endoscopy.

Clinical roleDescribed as an adjunctive measurement tool to complement manometry and endoscopy; should not be used alone for diagnostic or treatment decisions.

Policy changeFLIP technology for diagnosing Achalasia was added to the policy's list of unproven and not medically necessary procedures in the 05/01/2026 revision.