91033
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Esophageal pH monitoring is consideredmedically necessaryfor the following adults, children or adolescents who are able to report their symptoms in the following clinical situations:
- Documentation of abnormal esophageal acid exposure in endoscopy-negative individuals being considered for surgical antireflux repairs (pH study done after withholding antisecretory drug regimen for at least 1 week);or
- Evaluation of antireflux surgery in individuals who are suspected to have ongoing abnormal reflux (pH study done after withholding antisecretory drug regimen for at least 1 week);or
- Evaluation of individuals with either normal or equivocal endoscopic finding and reflux symptoms that are refractory to proton pump inhibitor (PPI) therapy (pH study after withholding antisecretory drug regimen for at least 1 week if the study is done to confirm excessive acid exposure or while taking the antisecretory drug regimen if the symptom-reflux correlation is to be scored);or
- To detect refractory reflux in individuals with chest pain after cardiac evaluation using a symptom reflux association scheme, preferably the symptoms association probability calculation (pH study done after a trial of PPI therapy for at least 4 weeks);or
- To evaluate an individual with suspected otolaryngologic manifestations (laryngitis, pharyngitis, chronic cough) of gastroesophageal reflux disease after symptoms have failed to respond to at least 4 weeks of PPI therapy (pH study done while the individual continues taking their antisecretory drug regimen to document the adequacy of therapy);or
1 Active Policy
ANTHEM-CG-MED-02 — CG-MED-02 Esophageal pH Monitoring
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