ModifiedUnitedHealthcarePolicy MMP039.15

Gastroesophageal and Gastrointestinal (GI) Services and Procedures

Medicare Advantage medical policy guidance for coverage and coding of selected gastroesophageal and gastrointestinal diagnostic and therapeutic services and procedures for UnitedHealthcare members; affects providers submitting claims and seeking prior authorization for these services.

Policy Summary

PayerUnitedHealthcare

PolicyGastroesophageal and Gastrointestinal (GI) Services and Procedures

Policy CodePolicy MMP039.15

Change TypeCoverage rationale updatesguidance linkage additions

Effective DateJun 1, 2025

Next Review Date

Key ActionFollow UnitedHealthcare prior authorization requirements and submit appropriate procedure codes and supporting documentation when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Coverage Rationale for Per Oral Endoscopic Myotomy (POEM) and Gastric Per Oral Endoscopic Myotomy (G-POEM) was updated.

Instruction to refer to UnitedHealthcare Commercial Medical Policy for Minimally Invasive Procedures for Gastric and Esophageal Diseases for states/territories with no LCDs/LCAs was added.

Updated list of CMS-related documents available in the Medicare Coverage Database to reflect the most current information.

06/01/2025Policy effective date

MultipleSections covered

Some LCDs/LCAsLocal coverage guidance

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.

ComprehensiveCode lists

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Coverage Criteria for GI Services and Procedures

Coding and Local Coverage Documents

Electrogastrography and Gastric Electrical Stimulation CPTsCPT

91132	Electrogastrography, diagnostic, transcutaneous [Refer to the UnitedHealthcare Commercial Medical Policy titled Gastrointestinal Motility Disorders, Diagnosis and Treatment.]
91133	Electrogastrography, diagnostic, transcutaneous; with provocative testing [Refer to the UnitedHealthcare Commercial Medical Policy titled Gastrointestinal Motility Disorders, Diagnosis and Treatment.]
43647	Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum.
43648	Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum.
43881	Implantation or replacement of gastric neurostimulator electrodes, antrum, open.
43882	Revision or removal of gastric neurostimulator electrodes, antrum, open.

POEM/G-POEM/Z-POEM, Neurostimulator, CTC and Virtual Upper GI CodesCPT

64590	Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver.
43499	Unlisted procedure, esophagus.
43999	Unlisted procedure, stomach.
43497	Lower esophageal myotomy, transoral (i.e., peroral endoscopic myotomy [POEM]).
74261	Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material.
74262	Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed.
76497	Unlisted computed tomography procedure (e.g., diagnostic, interventional).
76498	Unlisted magnetic resonance procedure (e.g., diagnostic, interventional).

CMS LCDs/LCAs referencedmixed

L35080	Select Minimally Invasive GERD Procedures (LCD)
A56863	Billing and Coding: Select Minimally Invasive GERD Procedures (LCA)
L34434	Upper Gastrointestinal Endoscopy and Visualization (LCD)
A56389	Billing and Coding: Upper Gastrointestinal Endoscopy and Visualization (LCA)
L34659	Endoscopic Treatment of GERD (LCD)
A56395	Billing and Coding: Endoscopic Treatment of GERD (LCA)
L38747	Peroral Endoscopic Myotomy (POEM) (LCD)
A58287	Billing and Coding: Peroral Endoscopic Myotomy (POEM) (LCA)

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Obtain prior authorization and submit correct codes

Follow UnitedHealthcare prior authorization processes and submit the appropriate procedure codes and supporting documentation as part of the authorization request; prior authorization requirements are governed by UnitedHealthcare commercial/Medicare Advantage procedures and referenced policies.

Include the procedure CPT/HCPCS codes listed in the policy when requesting authorization.
Provide supporting clinical documentation to demonstrate medical necessity per referenced guidance.

Prior Authorization

Follow plan or delegate prior authorization

For Medicare Advantage members whose utilization management and prior authorization are managed by a delegate, follow the plan or delegate's specific prior authorization and utilization management requirements.

Background and Scope

This Medical Policy references multiple diagnostic and therapeutic gastroenterology procedures including electrogastrography/electroenterography, gastric electrical stimulation (e.g., Enterra), endoscopic myotomy procedures such as POEM and G-POEM, computed tomographic colonography (CTC/virtual colonoscopy), and virtual upper gastrointestinal endoscopy. Coverage determinations may depend on applicable CMS National Coverage Determinations, Local Coverage Determinations/Articles where they exist, or UnitedHealthcare internal and commercial medical policy criteria; providers are expected to retain documentation to support medical necessity and to follow contractor- or plan-specific requirements when applicable.

Definitions and Procedure Descriptions

Electrogastrography / Electroenterography (definition)

DefinitionNoninvasive/transcutaneous diagnostic recording of gastric or intestinal electrical activity.

Medicare guidanceMedicare does not have a National Coverage Determination (NCD) for electrogastrography/electroenterography; Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) do not exist.

UnitedHealthcare referenceRefer to the UnitedHealthcare Commercial Medical Policy titled 'Gastrointestinal Motility Disorders, Diagnosis and Treatment' for coverage guidelines.

Gastric Electrical Stimulation Therapy (definition)

DefinitionImplantation of neurostimulator electrodes or pulse generator for gastric stimulation (example: Enterra).

Medicare guidance

Policy Revision History

2025-06-01Policy revisionLatest

Coverage Rationale updated for Per Oral Endoscopic Myotomy (POEM) and Gastric Per Oral Endoscopic Myotomy (G-POEM); instruction added to refer to the UnitedHealthcare Commercial Medical Policy titled 'Minimally Invasive Procedures for Gastric and Esophageal Diseases' for states/territories with no LCDs/LCAs; CMS-related documents list in the Medicare Coverage Database was updated; previous version MMP039.14 archived.

Policy Summary

PayerUnitedHealthcare

PolicyGastroesophageal and Gastrointestinal (GI) Services and Procedures

Policy CodePolicy MMP039.15

Change TypeCoverage rationale updatesguidance linkage additions

Effective DateJun 1, 2025

Next Review Date

Key ActionFollow UnitedHealthcare prior authorization requirements and submit appropriate procedure codes and supporting documentation when requesting coverage.

SourceLink

On This Page

Documentation Required

Retain/access documentation to support coverage

Providers are expected to retain or have access to appropriate documentation to support coverage decisions and authorization requests; this policy and related instructions should be used to guide documentation practices.

Billing Rule

Bill using listed CPT/HCPCS; support unlisted codes with documentation

Use the CPT/HCPCS codes listed in the policy for billing these procedures and include supporting documentation of the procedure and medical necessity; if using unlisted procedure codes (e.g., 43499, 43999, 76497, 76498), include adequate operative and clinical documentation to justify the unlisted code.

Examples of listed codes: 91132, 91133, 43647, 43648, 43881, 43882, 64590, 43497, 74261, 74262.
For unlisted procedure codes (43499, 43999, 76497, 76498), attach operative reports and clinical rationale.

Documentation Required

Retain records and submit accurate claims

Maintain and produce complete records supporting billed services and ensure claims are submitted accurately using CPT/CMS coding guidelines; when a delegate handles prior authorization, follow the delegate's requirements and still retain documentation.

Retain operative reports, imaging reports, and clinical notes used to support medical necessity.
Ensure coding on claims matches documentation and the policy's listed codes.

Denial Risk

Have documentation available on request or risk denial

Providers must be able to produce documentation when requested to support coverage decisions; lack of available documentation at the time of review may place claims at risk for denial.

Medicare does not have a National Coverage Determination (NCD) for gastric electrical stimulation therapy; LCDs/LCAs do not exist.

UnitedHealthcare referenceRefer to the UnitedHealthcare Commercial Medical Policy titled 'Gastrointestinal Motility Disorders, Diagnosis and Treatment' for coverage guidelines.

POEM / G-POEM / Z-POEM (definition)

DefinitionEndoscopic myotomy procedures performed via a transoral endoscopic approach for esophageal (POEM), gastric (G-POEM), or Zenker's diverticulum (Z-POEM) indications.

Medicare guidanceMedicare does not have an NCD for POEM/G-POEM/Z-POEM.

Local coverage implicationLCDs/LCAs exist for POEM and G-POEM and compliance with those local contractor policies is required where applicable; Z-POEM currently has no LCD/LCA.

Virtual Colonoscopy / CT Colonography (CTC) (definition)

DefinitionComputed tomographic colonography (CTC), also called virtual colonoscopy, is a CT-based imaging method for colon evaluation used diagnostically or for screening.

Medicare screening determinationEffective May 12, 2009, CMS determined that evidence is inadequate to conclude CTC is an appropriate colorectal cancer screening test; CTC for colorectal cancer screening remains nationally noncovered (NCD 210.3).

Coverage guidanceMedicare does not have an NCD for virtual colonoscopy overall; LCDs/LCAs do not exist for CTC in this policy — diagnostic (non‑screening) CTC coverage should follow referenced diagnostic imaging criteria (e.g., InterQual).

LCD / LCA (definition and policy role)

DefinitionLocal Coverage Determination (LCD) and Local Coverage Article (LCA) are Medicare contractor–level coverage policies and related billing/coding guidance referenced in this document.

Use in this policyWhere LCDs/LCAs exist (for example, POEM and G-POEM), compliance with those local contractor policies is required; the policy includes a table of specific LCDs/LCAs and contractor names.

Fallback guidanceFor states/territories without applicable LCDs/LCAs, refer to the UnitedHealthcare Commercial Medical Policy titled 'Minimally Invasive Procedures for Gastric and Esophageal Diseases.'