C9777 — Esophageal mucosal integrity testing by electrical impedance, transoral, includes esophagoscopy or esophagogastroduodenoscopy
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation that the infant/child is unable to report or describe reflux symptoms
- Documentation of the specific qualifying symptom(s) (unexplained apnea, bradycardia, refractory cough/wheeze/stridor/recurrent choking, persistent/recurrent laryngitis, or recurrent pneumonia)
- For impedance-pH monitoring, documentation of established GERD diagnosis, current PPI therapy, and inadequate symptomatic response to PPI
- Record that esophageal pH monitoring system selected is FDA-approved for the patient’s age and indication
Key Coverage Criteria
- Esophageal pH monitoring (catheter or wireless) is medically necessary for adults and for children/adolescents who are able to report symptoms.
- Document abnormal acid exposure in endoscopy-negative individuals being considered for surgical antireflux repair.
- Evaluate individuals after antireflux surgery who are suspected of having ongoing abnormal reflux.
- Evaluate individuals with normal or equivocal endoscopic findings and reflux symptoms refractory to proton pump inhibitor (PPI) therapy.
- Evaluate refractory reflux in individuals with chest pain after cardiac evaluation and after a 1-month trial of PPI therapy.
- Evaluate suspected otolaryngologic manifestations of GERD (laryngitis, pharyngitis, chronic cough) that have failed to respond to at least 4 weeks of PPI therapy.
5 Active Policies
BCBSIL-MED201.005 — Esophageal pH Monitoring
BCBSMT-MED201.005 — Esophageal pH Monitoring
BCBSNM-MED201.005 — Esophageal pH Monitoring
BCBSOK-MED201.005 — Esophageal pH Monitoring
MED201.005 — Esophageal pH Monitoring
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.