ModifiedUnitedHealthcarePolicy CS046OH.E

Gastrointestinal Disorders Diagnostic Procedures (for Ohio Only)

Defines coverage and medical necessity determinations for select gastrointestinal diagnostic procedures for UnitedHealthcare members in Ohio, including which procedures are considered unproven and not medically necessary.

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Disorders Diagnostic Procedures (for Ohio Only)

Policy CodePolicy CS046OH.E

Change TypeMaterial revisions to unproven procedures and code list

Effective DateApr 1, 2026

Next Review Date

Key ActionVerify prior authorization requirements and document prior testing when requesting MR defecography or procedures listed as unproven.

SourceLink

POLICY UPDATE CHANGES

Title changed from 'Gastrointestinal Motility Disorders, Diagnosis and Treatment (for Ohio Only)' to the current title and language pertaining to gastric electrical stimulation (GES) therapy was removed and relocated to a separate policy.

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

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

List of unproven and not medically necessary procedures was revised to add FLIP for diagnosing achalasia and to remove examples of certain gastric mapping systems and an impedance mucosal integrity test.

Applicable codes list was revised to remove CPT codes 43647, 43648, 43881, 43882, 64590, and 64595.

5procedures listed as unproven / not medically necessary

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CPT codes removed from Applicable Codes

Ohiopolicy geographic applicability

9 codescode groupings provided

0.78–0.96BSGM reported accuracy range

Coverage Criteria and Unproven Procedures

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 or 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, or for monitoring treatment response in GERD and EoE; Functional Lumen Imaging Probe (FLIP) technology for diagnosing Achalasia.

These procedures are listed collectively as not medically necessary due to insufficient evidence.

Device and test-specific coverage considerations

Coverage considerations and clinical criteria summarized from guidelines and evidence:

FLIP use: FLIP (EndoFLIP) may be used as a complementary assessment of esophagogastric junction opening dynamics and esophageal wall stiffness but should not be the sole basis for diagnosis or treatment decisions; do not use routinely for GERD diagnosis and not to diagnose eosinophilic esophagitis (may assist with severity assessment/monitoring).

Based on AGA practice update; utilization should follow disease-specific protocols and standardized analysis methods.

MRI defecography appropriate use: MRI defecography may be appropriate when anorectal manometry (ARM) and balloon expulsion test (BET) are inconclusive and structural causes are suspected; or when preoperative planning requires additional anatomic detail; or when fluoroscopic/video defecography is not available or contraindicated.

Reflects AGA/ACG/ASCRS guideline contexts and comparative evidence.

MRI defecography technical requirement: MRI defecography that omits an evacuation phase or has suboptimal technique (eg, inadequate rectal filling or supine-only non-evacuation imaging) has substantially lower sensitivity and may not replace evacuation proctography/fluoroscopic defecography as the reference standard.

Evacuation-phase imaging improves sensitivity for rectocele and enterocele versus non-evacuation MRI.

EGG / BSGM utility: Traditional low-resolution electrogastrography (EGG) has limited and heterogeneous evidence and is not proven to change management; body surface gastric mapping (BSGM) technologies show improved signal and phenotyping compared with low-resolution EGG but require larger validation and clinical utility studies to establish impact on patient-relevant outcomes.

Evidence includes systematic reviews, meta-analyses, and small observational studies with methodological heterogeneity.

Coverage considerations by modality

Coverage stance and criteria summaries inferred from clinical evidence and guideline statements in the document:

Electrogastrography / Body Surface Gastric Mapping: Electrogastrography (low-resolution/transcutaneous EGG) is considered experimental/unproven for routine clinical diagnosis due to limited, heterogeneous evidence and guideline non-recommendation; BSGM demonstrates improved performance characteristics in small studies but clinical utility for improving outcomes is not established.evidence insufficient for routine clinical coverage

See systematic reviews and comparative studies.

Esophageal Mucosal Integrity Testing (MI): Esophageal mucosal integrity testing by electrical impedance has limited-quality evidence from small studies and evidence reviews (Hayes, ECRI) that detect diagnostic patterns, but clinical utility and impact on outcomes have not been demonstrated; therefore it is not supported as a standalone diagnostic test for GERD, EoE, or non-GERD at this time.evidence insufficient for broad coverage as a standalone diagnostic

Guideline bodies do not yet endorse routine use.

Unproven and Not Medically Necessary Procedures (revised)

Policy revisions specify changes to procedures considered unproven or not medically necessary and relocation of therapy coverage rationale.

Unproven/Not Medically Necessary Updates: Functional Lumen Imaging Probe (FLIP) technology for diagnosing Achalasia was added to the list of unproven and not medically necessary procedures; specific examples of body surface gastric mapping systems (eg, Gastric Alimetry) and the MiVu mucosal integrity system were removed from the examples list. Language pertaining to gastric electrical stimulation (GES) therapy was removed from this policy and relocated to a separate policy. CPT codes 43647, 43648, 43881, 43882, 64590, and 64595 were removed from the applicable codes list.

See Policy History/Revision Information for summary of changes.

The following procedures are considered unproven and not medically necessary due to insufficient evidence of efficacy: 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 diagnosis/monitoring of GERD, eosinophilic esophagitis (EoE), and nonacid reflux; and Functional Lumen Imaging Probe (FLIP) technology for diagnosing achalasia.

Per the AGA practice update and the policy rationale, FLIP/EndoFLIP should not be used routinely to diagnose GERD or to make a diagnosis of eosinophilic esophagitis. FLIP is FDA-cleared and may provide complementary information on esophagogastric junction opening dynamics and esophageal wall stiffness, but clinicians should not base diagnosis or treatment decisions on FLIP assessment alone; it may be used to assist in severity assessment or therapeutic monitoring in selected cases.

Policy revisions removed language about gastric electrical stimulation (GES) therapy from this document and relocated GES coverage rationale and operational details to a separate UnitedHealthcare medical policy titled “Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Ohio Only).”

Information and coverage considerations specific to gastric electrical stimulation (GES) therapy have been relocated and are now addressed under the separate policy “Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases (for Ohio Only).” Providers should refer to that policy for GES-related coverage rules.

This policy references multiple diagnostic tests and devices and states the coverage stance as follows: MRI Defecography is listed as unproven/not medically necessary for routine evaluation of constipation and pelvic floor disorders; Electrogastrography (EGG), electroenterography, and body surface gastric mapping (BSGM) are considered investigational or unproven for routine diagnosis of gastric disorders including gastroparesis; Esophageal mucosal integrity testing (electrical impedance) is unproven for diagnosis or monitoring of GERD, EoE, and nonacid reflux; and FLIP/EndoFLIP is described as an FDA-cleared adjunctive tool for assessing sphincter dynamics but is included among technologies noted as unproven when used as a sole diagnostic method.

Traditional electrogastrography (EGG) and electroenterography are considered investigational/not established for routine clinical use. Systematic reviews and guideline statements report heterogeneous, low-quality evidence and conclude that EGG has not been shown to change patient management or outcomes and therefore is not supported for routine diagnostic use.

Major guideline reviews and evidence assessments do not recommend routine clinical use of esophageal mucosal integrity testing by electrical impedance. Published studies are limited in quality and size, and professional society guidance does not endorse mucosal impedance testing as a substitute for standard diagnostic methods for GERD or EoE.

As part of the policy revision, Functional Lumen Imaging Probe (FLIP) technology for diagnosing achalasia was explicitly added to the list of procedures considered unproven and not medically necessary. Although FLIP/EndoFLIP is FDA-cleared and may be used adjunctively, the policy specifies FLIP is unproven as a standalone diagnostic for achalasia and related treatment decisions.

Applicable Codes and Coding Changes

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.

Previously listed CPT codes removedCPT

43647	Removed CPT code (exact description not provided in this section)
43648	Removed CPT code (exact description not provided in this section)
43881	Removed CPT code (exact description not provided in this section)
43882	Removed CPT code (exact description not provided in this section)
64590	Removed CPT code (exact description not provided in this section)
64595	Removed CPT code (exact description not provided in this section)

Removed from Applicable CodesCPT

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

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Application / Plan-specific verification

This policy applies only in Ohio. Verify federal, state (Ohio Administrative Code 5160), and contractual benefit plan requirements before applying this policy; those requirements govern if there is a conflict.

State-specific policy: Ohio only — OAC 5160-101 may apply

Prior Authorization

Prior Authorization Required — verify with plan

Prior authorization may be required per UnitedHealthcare and Ohio Medicaid rules. Providers should check current prior authorization requirements with the member's plan before scheduling services.

Confirm prior authorization with UnitedHealthcare and any applicable Ohio Medicaid operational requirements

Prior Authorization

Background and Scope

Constipation, fecal incontinence, and gastroparesis are common gastrointestinal conditions that often require objective diagnostic testing. Gastric emptying scintigraphy is cited as the reference standard for evaluating gastroparesis, and standardized, validated protocols are emphasized for interpretation of GI motility tests. Objective testing (e.g., anorectal manometry, rectal balloon expulsion testing) is typically used as initial evaluation for defecatory disorders, with advanced imaging such as MRI defecography reserved for selected indications when prior testing is inconclusive or structural causes are suspected.

Definitions

Achalasia — definition of achalasia

DefinitionA primary esophageal motor disorder of unknown etiology 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 of EGG

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

Clinical contextStudies and systematic reviews report limited and heterogeneous evidence for traditional low‑resolution EGG; body surface gastric mapping (BSGM) shows improved signal and phenotyping versus EGG but clinical utility to improve patient‑relevant outcomes is not established.

Regulatory statusInstruments for cutaneous electrogastrography and body surface gastric mapping are regulated by the FDA as Class II devices (product codes MYE or FFX).

Policy Summary

PayerUnitedHealthcare

PolicyGastrointestinal Disorders Diagnostic Procedures (for Ohio Only)

Policy CodePolicy CS046OH.E

Change TypeMaterial revisions to unproven procedures and code list

Effective DateApr 1, 2026

Next Review Date

Key ActionVerify prior authorization requirements and document prior testing when requesting MR defecography or procedures listed as unproven.

SourceLink

On This Page

EndoFLIP / FLIP technology: EndoFLIP is FDA-cleared for measuring pressure and dimensions in GI sphincters and is intended as an adjunctive tool; use is recommended as part of comprehensive evaluation rather than as the sole diagnostic modality.adjunctive use recommended

AGA advises FLIP not be used alone for diagnosis or treatment decisions and to follow disease-specific protocols.

Prior Authorization for MR Defecography after Inconclusive Testing

If ARM and balloon expulsion testing (BET) are inconclusive for suspected defecatory disorders, consider defecography. MR defecography may be appropriate when prior testing is inconclusive, but providers should follow a stepwise evaluation and obtain prior authorization when required.

Stepwise approach: ARM and BET first; if equivocal, consider fluoroscopic defecography or MR defecography
Obtain prior authorization when MR defecography is planned after inconclusive initial testing

Documentation Required

MRI Defecography — protocol and documentation expectations

Technical adequacy and protocol details must be documented. For MRI defecography, document whether an evacuation-phase (dynamic) study was obtained and include relevant protocol parameters and findings.

Document if evacuation-phase imaging was performed (higher sensitivity when obtained)
Include protocol details: patient position, amount/consistency of rectal contrast or gel, and whether static and dynamic images obtained

Prior Authorization

Verify Prior Authorization for Updated/Removed Codes

Providers should verify prior authorization requirements for CPT/HCPCS codes listed in the Applicable Codes section, especially when codes are removed or changed. Prior authorization rules may have changed following code updates.

Verify current PA requirements for codes removed in the 04/01/2026 update
Confirm billing code applicability with the payer before service delivery

Note

Use of InterQual® and UnitedHealthcare Criteria

Use InterQual® criteria as UnitedHealthcare's primary medical/surgical criteria. If InterQual® does not have applicable criteria, providers should follow UnitedHealthcare Medical Policies, Coverage Determination Guidelines, and/or Utilization Review Guidelines (as approved for Ohio Medicaid). When InterQual® is not applicable, reference this policy and state or contractual requirements.

Primary criteria: InterQual®
Fallback: UnitedHealthcare policies and Ohio-approved guidelines when InterQual® is not applicable

Denial Risk

Risk of Denial for Unproven Procedures

For procedures identified in this policy as unproven (e.g., MRI defecography for some indications, electrogastrography, mucosal impedance testing, FLIP for achalasia diagnosis), requests may be denied as not medically necessary if documentation does not meet policy criteria or if the procedure is listed as unproven.

Unproven/not medically necessary examples: MRI defecography for certain indications, electrogastrography/Alimetry, mucosal impedance (MiVu) testing, FLIP to diagnose achalasia

Documentation Required

Use Adjunctively — FLIP and Mucosal Impedance

Adjunctive tests such as EndoFLIP (FLIP) and mucosal impedance testing should be used as complementary information and not as the sole basis for diagnosis or treatment decisions. Document how these adjunctive results informed management and include corroborating clinical and diagnostic data.

Do not use FLIP or MI testing alone to make a diagnosis or treatment decision
Document complementary role and how findings influenced management

Documentation Required

Gastroparesis Diagnostic Pathway and Protocol Adherence

For gastroparesis evaluation, scintigraphic gastric emptying studies are the reference standard. Ensure adherence to validated standardized protocols (meal content, duration, and complete ingestion) and document protocol adherence and test adequacy in the record.

Scintigraphy is the reference standard — document meal protocol, imaging duration, and full meal consumption
Adhere to validated standardized study protocols and include protocol details in the report

Documentation Required

Technical Success and Diagnostic Adequacy — document limitations

Document technical success and diagnostic adequacy for imaging and functional tests. For example, MRI defecography has lower technical success rates compared with video/fluoroscopic defecography; include any limitations that may affect interpretation.

Report technical success (fully diagnostic, partially diagnostic, nondiagnostic)
Note factors affecting adequacy (patient position, evacuation phase obtained, gel/contrast amount)

Prior Authorization

Required Plan-Specific Verification and Compliance

Before applying this policy, confirm that coverage decisions align with governing federal, state (OAC), and contractual requirements. UnitedHealthcare policies may be modified; always check the current policy and payer communications.

Coverage governed by federal/state/contractual terms; in case of conflict, those terms govern
Check for policy updates and payer notices prior to service authorization

Functional Lumen Imaging Probe (FLIP) — definition of FLIP

DefinitionA catheter‑based endoscopic system designed to assess esophageal motility and measure distensibility (eg, distensibility index) at the esophagogastric junction, providing insight into lower esophageal sphincter compliance.

Clinical guidanceAGA notes FLIP should be used as a complementary assessment of esophagogastric junction opening dynamics and esophageal wall stiffness and not as the sole basis for diagnosis or treatment decisions; use should follow disease‑specific protocols.

Regulatory noteEndoFLIP (a FLIP system) has been available since 2009; the EndoFLIP System is FDA 510(k)‑cleared for use measuring pressure and dimensions in the esophagus and related sphincters (see EndoFLIP 510(k)).

FLIP / EndoFLIP — device description and regulatory note

Device descriptionEndoFLIP/FLIP is an intraluminal impedance planimetry system that measures simultaneous pressure and diameter to assess esophagogastric junction opening dynamics, distensibility, and wall stiffness.

Intended useIntended as an adjunctive procedure to other diagnostic methods as part of a comprehensive evaluation of patients with gastrointestinal motility disorders—not a standalone diagnostic tool.

Regulatory noteEndoFLIP received 510(k) clearance (K170833) and has limited penetrance outside specialized centers; FDA clearance alone is not a basis for coverage per the policy.

Evacuation-phase MRI defecography — definition/description

DefinitionMRI defecography performed with dynamic imaging during the act of defecation (evacuation phase) to assess pelvic floor anatomy, dynamic motion, and rectal evacuation.

Diagnostic valueEvacuation‑phase MRI increases sensitivity for detecting rectocele and enterocele compared with MRI without evacuation; omission of evacuation phase reduces sensitivity and may not replace evacuation proctography/fluoroscopic defecography.

Appropriate useMay be appropriate when anorectal manometry and balloon expulsion testing are inconclusive, for preoperative planning when structural causes are suspected, or when fluoroscopic defecography is unavailable or contraindicated.

BSGM (Body Surface Gastric Mapping) — definition and clinical use

DefinitionHigh‑resolution, noninvasive surface mapping of gastric myoelectrical activity (eg, Gastric Alimetry) intended to phenotype gastric rhythm abnormalities and correlate electrical patterns with symptoms.

Evidence summaryStudies show BSGM provides improved signal fidelity and better patient‑level classification accuracy versus traditional EGG, but available evidence is limited and of low quality regarding impact on patient‑relevant outcomes.

Regulatory statusInstruments for body surface gastric mapping are regulated by the FDA as Class II devices (product code MYE/FFX); clinical utility studies are needed for broader adoption.

EndoFLIP / FLIP — impedance planimetry system definition (alternate entry)

DefinitionAn impedance planimetry system that measures lumen diameter and intraluminal pressure to calculate distensibility and assess sphincter function in the esophagus, pylorus, and anal sphincters.

Intended roleIndicated to be used as an adjunct to other diagnostic methods as part of a comprehensive evaluation of gastrointestinal motility disorders rather than as a sole diagnostic test.

Regulatory contextEndoFLIP received FDA 510(k) clearance (K170833); FDA clearance does not by itself imply coverage under this policy.

Achalasia — added definition in policy (revision)

Addition to policyA specific definition for Achalasia was added to the policy during the 04/01/2026 revision; the policy defines achalasia as an esophageal motor disorder with impaired EGJ relaxation and loss of organized peristalsis.

Change noteThe policy history documents the addition of the Achalasia definition and other definition updates as part of the revision on 04/01/2026.

Source referenceSee Definitions section and Policy History/Revision Information for the exact added language and revision date.

Functional Lumen Imaging Probe (FLIP) — added definition in policy (revision)

Addition to policyA definition for Functional Lumen Imaging Probe (FLIP) was added to the policy on 04/01/2026 describing it as a catheter‑based endoscopic system to assess esophageal motility and distensibility at the esophagogastric junction.

Change notePolicy History records the added FLIP definition as part of the revision and notes FLIP was explicitly included among revised unproven procedures.

Clinical contextThe policy cites AGA guidance emphasizing FLIP’s adjunctive role and recommends documentation that FLIP findings complement other diagnostic information.