ModifiedUnitedHealthcarePolicy CS046NM.D

Gastrointestinal Disorders Diagnostic Procedures (for New Mexico Only)

Medical policy governing coverage and medical necessity determinations for diagnostic procedures related to gastrointestinal disorders (e.g., MRI defecography, electrogastrography, FLIP) for UnitedHealthcare members in New Mexico.

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Disorders Diagnostic Procedures (for New Mexico Only)

Policy CodePolicy CS046NM.D

Change TypeMaterial updates — added FLIP as unprovenremoved GES languageremoved select CPT codes

Effective DateApr 1, 2026

Next Review Date

Key ActionDocument objective evidence and adherence to validated standardized study protocols (e.g., gastric emptying scintigraphy) when submitting claims for gastrointestinal function testing.

SourceLink

POLICY UPDATE CHANGES

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

Language pertaining to gastric electrical stimulation (GES) therapy relocated; refer to a separate Medical Policy titled 'Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for New Mexico Only)'.

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

Examples previously listed of cutaneous/mucous/serosal electrogastrography, electroenterography, or body surface gastric mapping (including Gastric Alimetry System, G-Tech Gut Tracker) and Esophageal Mucosal Integrity Testing by electrical impedance (MiVu) were removed from the unproven examples list.

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

1state-specific (NM)

4unproven procedures

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2026-04-01summary date

Coverage Criteria and Policy Direction

inv-01: Unproven / Not Medically Necessary

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

Unproven 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 GERD, eosinophilic esophagitis (EoE), and nonacid reflux disease or for monitoring treatment response; Functional Lumen Imaging Probe (FLIP) technology for diagnosing achalasia.

These items are explicitly listed as unproven and not medically necessary in the policy.

inv-02: Gastroparesis - Diagnostic Criteria

Diagnosis of gastroparesis requires objective evidence:

Gastroparesis diagnostic requirement: Objective evidence of clearly delayed gastric emptying in symptomatic patientsScintigraphy is the reference standard using standardized meal protocols and adequate imaging duration

Clinical utility depends on complete consumption of adequate test meals and adherence to validated standardized study protocols.

inv-03: Coverage-relevant evidence summaries

Summary of coverage-relevant guidance and evidence:

FLIP (EndoFLIP) clinical role: FLIP is an FDA‑approved measurement tool available since 2009 that may be useful as a complementary assessment for patients who cannot tolerate or complete standard manometry; clinicians should not make diagnoses or treatment decisions based on FLIP assessment alone and utilization should follow disease‑specific protocols.

ACG/AGA guidance: FLIP is evolving and should complement — not replace — standard diagnostics.

MRI defecography (MRD) role: MR defecography can identify structural causes of outlet obstruction and may be useful when anorectal manometry (ARM) and balloon expulsion testing (BET) are equivocal or for preoperative planning, but systematic reviews and comparative studies do not establish MRD as a replacement for evacuation proctography and sensitivity depends on performing the evacuation phase.

Evidence is mixed; MRD may serve as a complementary or triage test rather than the reference standard.

EGG and BSGM (Gastric Alimetry) stance: Traditional electrogastrography (EGG) lacks consistent clinical utility; body surface gastric mapping (BSGM) demonstrates improved signal characteristics and patient‑level classification versus low‑resolution EGG in observational studies, but overall evidence quality is low and clinical utility (improvements in patient‑relevant outcomes) has not been established.

inv-04: Evidence summary and implications for coverage

Evidence and guideline-based considerations

BSGM vs EGG evidence: Observational studies (including multicenter and single‑center series) report that BSGM provides tighter frequency ranges, stronger symptom correlations, and higher patient‑level classification accuracy compared with traditional low‑resolution EGG, but limitations include small sample sizes, heterogeneous methods, and proprietary processing differences.

Supports potential utility but does not demonstrate improved patient outcomes.

Guideline stance on EGG: Professional society guidance does not support routine use of EGG for diagnosis of gastroparesis; additional standardized protocols and outcome studies are needed before adoption into routine clinical practice.

AGA/ACG guidance and systematic reviews recommend further study.

MI testing and regulatory context: Hayes and ECRI evidence reviews conclude that MI testing has limited published clinical evidence; although MiVu has had de novo and 510(k) clearances, FDA clearance alone is informational and does not establish clinical utility or coverage.

Device regulatory status should not be interpreted as sufficient evidence for coverage without supporting clinical utility data.

inv-05: Revised coverage direction and unproven procedures

Policy changes and coverage direction for New Mexico plans

Policy scope and operational referrals: Language pertaining to gastric electrical stimulation (GES) therapy has been removed and readers are referred to the separate Medical Policy titled 'Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for New Mexico Only)'.

Operational redirection to another policy for GES.

Revisions to unproven procedures list: Functional Lumen Imaging Probe (FLIP) technology for diagnosing achalasia was added to the list of procedures designated unproven and not medically necessary; conversely, specific example devices (including certain body surface gastric mapping systems and the MiVu MI system) were removed from the example list but the underlying technologies remain subject to evidence review and coverage determinations.

These changes are effective per the policy revision history for New Mexico plans.

The procedures listed in the Coverage Rationale are designated as unproven and not medically necessary because the available evidence does not demonstrate sufficient efficacy to support routine clinical use. Examples explicitly called out include MRI defecography for evaluation of constipation and anorectal/pelvic floor disorders; cutaneous, mucous, or serosal electrogastrography (EGG), electroenterography, or body surface gastric mapping for gastric or intestinal disorders including gastroparesis; esophageal mucosal integrity testing by electrical impedance for GERD, EoE, or nonacid reflux disease; and Functional Lumen Imaging Probe (FLIP) technology for diagnosing achalasia.

Clinical guidance and evidence summaries advise caution in routine use of FLIP: professional society guidance indicates that FLIP is a complementary assessment and that clinicians should not make a diagnosis or treatment decision based on FLIP alone, and FLIP should not be used in routine diagnostic assessments of GERD. Similarly, evidence reviews find insufficient data

Available studies and published reviews conclude that these emerging technologies are not sufficiently developed to replace standard diagnostic methods. Reviews (Hayes, ECRI) identify limited or low-quality evidence and emphasize the need for larger clinical validity and clinical utility studies before these methods can be considered substitutes for established testing pathways that demonstrably improve patient outcomes.

Policy revisions removed certain previously listed examples from the unproven procedures list and relocated language on gastric electrical stimulation (GES) to a separate policy. Where example devices or systems were removed from the list, the policy text and supporting materials were updated to reflect that those items are no longer explicitly listed in this policy and that coverage decisions for GES are addressed in the referenced policy.

Examples of procedures previously included among unproven or not medically necessary technologies include MRI Defecography, cutaneous/mucous/serosal electrogastrography, electroenterography, and body surface gastric mapping (BSGM) such as the Gastric Alimetry system; these modalities were discussed in the policy as lacking sufficient evidence to support routine clinical use.

MRI defecography is not supported as a routine replacement for conventional evacuation proctography; available data indicate it is not consistently superior and may have lower technical success in some series. Likewise, cutaneous electrogastrography (EGG) and newer high-resolution body surface gastric mapping techniques (BSGM) have not been demonstrated to substitute for validated reference tests (for example, gastric emptying scintigraphy) in a way that improves clinical outcomes.

Published evidence is insufficient to support mucosal impedance (MI) testing as a sole diagnostic screening tool for GERD; ECRI and Hayes reviews conclude available studies are limited in size and quality and that clinical utility—meaning demonstrable impact on management or patient-relevant outcomes—has not been established.

Functional Lumen Imaging Probe (FLIP) technology is included in the policy list of procedures considered unproven and not medically necessary for diagnosing achalasia. Professional guidance characterizes FLIP as an adjunctive measurement tool and emphasizes it should be used as a complementary assessment rather than as a standalone diagnostic test for achalasia.

Applicable Codes and Regulatory Identifiers

Applicable Codes (reference list)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.

Device product codes / regulatory identifiersmixed

MYE / FFX

FDA product codes referenced for cutaneous electrogastrography and related devices

MiVu product codemixed

QIS	MiVu Mucosal Integrity Testing System product code (searchable in FDA database)

EndoFLIP regulatory identifiermixed

K170833

EndoFLIP 510(k) ID

Previously listed CPT codes removedCPT

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

Gastric emptying testing standard

Reference standardGastric emptying scintigraphy is the reference standard for measurement of gastric emptying; interpretation depends on complete consumption of standardized test meals and adequate duration of imaging.

Protocol requirementUse validated, standardized meal protocols prior to scintigraphy to ensure interpretable results.

Imaging durationAdequate duration of imaging is required for accurate assessment of gastric emptying; clinical utility depends on sufficient imaging time per standardized protocols.

Documentation expectationProviders should document adherence to standardized scintigraphy protocols and confirm complete consumption of the test meal when submitting records.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization
Reference Codes and Prior Authorization Implications
The following procedure and diagnosis codes are provided for reference only and do not by themselves authorize coverage or payment. Inclusion of a code does not imply the service is covered under a member's benefit plan. Prior authorization may be required per the member's federal, state, or contractual benefit requirements; when submitting for prior authorization, include supporting clinical documentation as described below.
Listing of codes is not all-inclusive; benefit coverage is determined by federal, state, or contractual requirements and applicable laws.
Prior authorization requirements, if any, should be verified prior to scheduling and claims submission.

Prior Authorization
MR Defecography (MRD) Prior Authorization Guidance
Magnetic resonance defecography (MRD) is considered complementary to standard anorectal physiologic testing and should generally not be ordered as a first-line replacement for validated tests. Prior authorization for MRD, when required, should document prior testing and clinical indications as outlined below.
Perform anorectal manometry (ARM) and rectal balloon expulsion testing (BET) prior to MRD unless these tests are unavailable or contraindicated.

Clinical Background and Scope

Constipation, fecal incontinence, and gastroparesis are common disorders that may require objective testing to determine underlying dysfunction. For gastroparesis, diagnosis requires objective evidence of delayed gastric emptying with radionuclide scintigraphy considered the reference standard using standardized meal protocols and adequate imaging duration. For anorectal and defecatory complaints, standard testing typically begins with anorectal manometry and balloon expulsion testing, with advanced imaging such as MRI defecography considered when these tests are inconclusive or for preoperative planning. Emerging tests (EGG/BSGM, MI testing, FLIP, MR defecography) have been evaluated, but current evidence does not establish them as replacements for validated diagnostic pathways that inform treatment and improve patient outcomes.

Definitions and Glossary

Achalasia — definition

DefinitionAchalasia is a 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.

Etiology noteOf unknown etiology; pathology involves myenteric plexus degeneration.

Clinical implicationImpaired EGJ relaxation and absent peristalsis underlie dysphagia and other esophageal motility symptoms.

Electrogastrography (EGG)

DefinitionElectrogastrography (EGG) is a noninvasive method for measuring gastric myoelectrical activity using cutaneous electrodes placed on the abdominal skin over the stomach.

Clinical utility

Policy Revision History

2026-04-01title_change_and_content_relocationLatest

Title changed from 'Gastrointestinal Motility Disorders, Diagnosis and Treatment (for New Mexico Only)' to the current title, and language pertaining to gastric electrical stimulation (GES) therapy was removed and referred to a separate Medical Policy for minimally invasive upper GI procedures.

2026-04-01unproven_list_update_addition

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

2026-04-01unproven_list_update_removals

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Disorders Diagnostic Procedures (for New Mexico Only)

Policy CodePolicy CS046NM.D

Change TypeMaterial updates — added FLIP as unprovenremoved GES languageremoved select CPT codes

Effective DateApr 1, 2026

Next Review Date

Key ActionDocument objective evidence and adherence to validated standardized study protocols (e.g., gastric emptying scintigraphy) when submitting claims for gastrointestinal function testing.

SourceLink

On This Page

ECRI and systematic reviews call for further validation and clinical utility studies before routine adoption.

Esophageal mucosal integrity (MI) testing evidence: Published reviews (Hayes, ECRI) and small studies report that MI patterns may distinguish GERD, EoE, and non‑GERD, but current evidence is limited and clinical utility for outcomes or as a sole diagnostic replacement is not established.

Additional clinical validity and clinical utility studies are needed.

PlaceholderN/A

NoteThis block is retained as a placeholder per layout plan; no specific thresholds or values provided in the policy fragment.

Policy revision referenceSee Policy History (04/01/2026) for recent changes and relocation of related content.

MRD may be appropriate when ARM and BET results are inconclusive or when structural pathology is suspected and documented.

Prior authorization requests for MRD must include results of ARM and BET and a clear clinical rationale explaining why MRD is necessary.

MRD is not supported as superior to conventional (fluoroscopic/barium) defecography based on current evidence; consider denial when MRD is requested as a replacement without supporting documentation.

Note
Device Clearance and Regulatory Notes
Devices used for cutaneous electrogastrography, electroenterography, and body surface gastric mapping are regulated by the U.S. Food and Drug Administration as Class II devices. Specific devices (e.g., MiVu Mucosal Integrity Testing System) have received FDA de novo clearance and 510(k) notifications; FDA clearance alone does not determine coverage.
Cutaneous electrogastrography / body surface gastric mapping devices — FDA Class II (product codes MYE or FFX).
Radiopaque markers for colonic transit testing — FDA cleared (product code FFX).
MRI systems used for MRD — 510(k) listings searchable by product code LNH.
MiVu Mucosal Integrity Testing System — FDA de novo clearance (Dec 23, 2019) and 510(k) K230056.

Prior Authorization
Related Policy for Gastric Electrical Stimulation (GES)
Coverage and prior authorization for gastric electrical stimulation (GES) and related therapies have been moved to a separate UnitedHealthcare medical policy. Providers must follow that policy's prior authorization and documentation requirements when requesting GES.
Refer to the Medical Policy titled 'Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for New Mexico Only)' for GES coverage and prior authorization guidance.
Do not include GES requests under this policy; submit under the referenced policy instead.

Denial Risk
Denial Triggers for Unproven or Not Medically Necessary Procedures
Procedures identified in this policy as unproven or not medically necessary may be denied when requested as replacements for validated standard tests, when requested without supporting documentation, or when requested to guide therapy despite insufficient evidence of clinical utility.
Denial may be triggered when MRD, esophageal mucosal integrity testing, cutaneous electrogastrography/BSGM, or FLIP are requested instead of validated reference tests without documentation justifying the alternative.
Denial may occur if the request lacks objective evidence of prior standard testing (e.g., ARM and BET before MRD; gastric emptying scintigraphy for gastroparesis evaluation).
Requests citing device FDA clearance alone without clinical evidence of effectiveness may be denied.

Denial Risk
Limitations of MRD, FLIP, and Emerging Diagnostics
Current evidence is insufficient to conclude that MR defecography (MRD), esophageal mucosal integrity testing, cutaneous electrogastrography/body surface gastric mapping, or FLIP provide improved clinical outcomes over established reference tests. Requests asserting superiority of these modalities should include high-quality evidence; absent that, denials are supportable.
MRD: existing evidence does not demonstrate clear superiority to conventional fluoroscopic/barium defecography.
Esophageal mucosal integrity testing and BSGM: limited published clinical data showing clinical utility or impact on management; additional validation studies needed.
FLIP for diagnosing achalasia: insufficient evidence to support routine diagnostic replacement of reference tests.

Note
Evidence Reviews Conclude Data Are Limited
Published clinical studies and third-party evidence reviews conclude that available data for esophageal mucosal integrity testing (MI) and some other emerging diagnostics are limited in size, generalizability, and assessment of clinical utility. Hayes and ECRI reviews recommend continued evidence monitoring and additional larger validation and clinical utility studies before these technologies can replace standard diagnostics.
Hayes found very low-quality studies and assigned only weak support as an adjunctive diagnostic tool, noting lack of data on undiagnosed populations and clinical utility.
ECRI concluded published evidence is limited and called for larger diagnostic accuracy and clinical utility studies.
Published single-center and small cohort studies (e.g., Patel 2019, Choksi 2018) provide preliminary diagnostic signal but are insufficient alone to change coverage policy.

Documentation Required
Required Clinical Documentation and Protocol Adherence
Documentation submitted for prior authorization or claim adjudication must include objective evidence, adherence to validated standardized study protocols, and relevant prior test results. Documentation should demonstrate clinical indication and how the requested test will affect management.
For gastroparesis evaluations, provide gastric emptying scintigraphy results performed per standardized protocol (protocol details and timing documented).
For MRD requests, include ARM and BET results and a clear clinical rationale for MRD (e.g., inconclusive ARM/BET, suspected structural lesion).
For MI testing or FLIP requests, include prior endoscopic, histologic, or physiologic testing results that justify use of the device and explain how results will change management.
Include relevant clinical notes, prior imaging or test reports, and any noninvasive testing that has been attempted.

Documentation Required
Supporting Clinical Documentation for MRD, FLIP, and Intraprocedural MI Measurements
When supporting MRD or FLIP authorization requests, explicitly include prior testing results and clinical detail to establish medical necessity. For MI measurements obtained intraprocedurally, document MI measurement technique, recorded values/patterns, and correspondence to clinical findings or pathology.
MRD/FLIP authorization should include: ARM and BET results (dates and numeric values where applicable), clinical history indicating failure of conservative therapy, and specific question MRD/FLIP is intended to answer.
Intraprocedural MI documentation should include device used, measurement sites, MI values/patterns, any adverse events, and impact on procedural decisions (e.g., biopsy, additional testing).
Lack of such supporting documentation may result in denial as not medically necessary.

Studies to date do not demonstrate consistent diagnostic accuracy or impact on patient outcomes; further standardized validation is needed.

Research roleMay be used in clinical research or adjunctive assessments but is not established as a replacement for scintigraphy.

Magnetic Resonance Defecography

DefinitionMagnetic Resonance Defecography is a noninvasive MRI test obtained at stages of defecation to evaluate pelvic floor anatomy, dynamic motion, and rectal evacuation.

Comparative performanceSystematic reviews show MRD specificity can be high for certain findings but sensitivity depends on performing the evacuation phase; MRD is not consistently superior to evacuation proctography.

Appropriate useMay be useful when anorectal manometry (ARM) and balloon expulsion testing (BET) are equivocal or for preoperative planning, not as routine replacement of conventional defecography.

Functional Lumen Imaging Probe (FLIP)

DefinitionFunctional Lumen Imaging Probe (FLIP) is a catheter-based endoscopic system designed to assess esophageal motility and measure the distensibility index at the esophagogastric junction.

RoleFLIP provides insights into EGJ compliance and opening dynamics and may complement manometry, particularly when manometry cannot be completed or tolerated.

Usage guidanceClinicians should not make diagnosis or treatment decisions based solely on FLIP; it should complement standard diagnostics and follow disease-specific protocols.

FLIP / EndoFLIP

Device descriptionFLIP/EndoFLIP is an FDA-approved measurement tool that records simultaneous pressure and diameter to evaluate esophagogastric junction opening dynamics and esophageal wall stiffness during endoscopy.

AvailabilityEndoFLIP has been available since 2009; limited penetrance outside specialized centers due to limited supporting data and lack of standardized protocols.

Clinical recommendationUse FLIP as an adjunctive tool; do not use routinely for GERD diagnosis or as the sole basis for treatment decisions.

MRI defecography (MRD)

DefinitionMRI defecography (MRD) is dynamic pelvic MRI performed during evacuation to assess pelvic floor structure and function as an alternative to fluoroscopic evacuation proctography.

Evidence summaryMeta-analysis indicates MRI sensitivity is higher when performed with an evacuation phase; overall MRD does not consistently outperform evacuation proctography as the reference standard.

Use caseConsider MRD for structural evaluation or when ARM/BET are inconclusive or for surgical planning rather than routine replacement of conventional defecography.

BSGM (Gastric Alimetry)

DefinitionBSGM (Gastric Alimetry) is a noninvasive body surface gastric mapping system that records gastric myoelectrical activity and produces spectral and spatial biomarkers for phenotyping gastric disorders.

Comparative findingsObservational studies report BSGM shows improved frequency precision, stronger symptom correlations, and higher patient-level classification accuracy versus traditional low-resolution EGG, but evidence quality is low to very low.

Clinical utilityAdditional clinical validity and clinical utility studies are needed; current evidence does not demonstrate improved patient outcomes from routine use.

BSGM / Gastric Alimetry

TechniqueBSGM (Gastric Alimetry) is a high-resolution body surface gastric mapping technique capturing spectral and spatial biomarkers to analyze gastric electrical activity.

Performance vs EGGStudies (e.g., Schamberg et al.) report substantial performance improvements of BSGM over EGG in frequency range precision, symptom correlations, and patient-level classification accuracy.

Evidence limitationsStudies are limited by small samples, heterogeneous methods, and need for standardized processing; clinical outcome benefits remain unproven.

Mucosal Impedance (MI) testing / MiVu

DefinitionMucosal Impedance (MI) testing (MiVu) is an intraprocedural balloon catheter system that measures esophageal epithelial impedance along the esophagus during EGD to identify patterns associated with GERD, EoE, or non-GERD.

Evidence summaryProspective multicenter studies report MI patterns differ among GERD, EoE, and non-GERD, but reviews conclude clinical utility and impact on outcomes are not yet established.

Regulatory noteExamples of MiVu were removed from the policy's unproven examples list in the revision; FDA clearances exist but are informational for coverage.

Achalasia (glossary addition)

Glossary additionAchalasia: A primary esophageal motor disorder characterized by degeneration of the myenteric plexus resulting in impaired EGJ relaxation and loss of organized peristalsis.

SourceDefinition added to the policy glossary (see Definitions section).

Policy revisionAchalasia definition was explicitly added in the 04/01/2026 policy revision.

Functional Lumen Imaging Probe (FLIP) (glossary addition)

Glossary additionFunctional Lumen Imaging Probe (FLIP): A catheter-based endoscopic system to assess esophageal motility and distensibility at the esophagogastric junction.

Clinical noteFLIP/EndoFLIP is FDA-approved as a measurement tool but should be used as an adjunct; added to glossary in the 04/01/2026 revision.

Policy impactFLIP technology for diagnosing Achalasia was added to the unproven/not medically necessary list in the policy revision.

Examples of cutaneous, mucous, or serosal electrogastrography/electroenterography/body surface gastric mapping (including Gastric Alimetry System and G-Tech Gut Tracker) and Esophageal Mucosal Integrity Testing (MiVu) were removed from the examples list of unproven procedures.

2026-04-01definitions_updated

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

2026-04-01coding_updates

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

2026-04-01supporting_sections_revised

Supporting sections including Description of Services, Clinical Evidence, FDA, and References were updated to reflect current information; previous policy version CS046NM.C was archived.