C9787, Gastric electrophysiology mapping with simultaneous patient symptom profiling
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Symptom logging requirement: use of a "validated symptom-logging App" during BSGM/Gastric Alimetry testing.
- Reference to normative ranges and metrics: results should be "referenced to normative ranges" and interpreted using BSGM spectral metrics (e.g., Principal Gastric Frequency, GA Rhythm Index, BMI-adjusted amplitude, fed:fasted amplitude ratio).
- For pediatric HREM: patient must tolerate the procedure and be able to swallow 5-ml boluses ("The youngest patient able to tolerate the procedure and swallow 5-ml boluses was 1 year of age").
- Reporting should include spectral/ spatial biomarker analyses and correlation with symptom profiles and psychometrics where applicable.
Key Coverage Criteria
- Colon motility (manometric) study, minimum 6 hours continuous recording (CPT 91117) — covered if selection criteria are met.
- CPT 78264 Gastric emptying imaging study (eg, solid, liquid, or both) — covered if selection criteria are met.
- Use of colonic motility studies (colonic manometry) to guide decision-making for surgery in children with refractory colonic motility / defecatory disorders.
- Radionuclide gastric emptying study for the evaluation of gastrointestinal motility disorders, and gastroparesis.
- Magnetic resonance enterography to evaluate and monitor Crohn's disease and other small bowel disorders.
- CPT 91117 Colon motility (manometric) study, minimum 6 hours continuous recording (including provocation tests, eg, meal, intracolonic balloon distention, pharmacologic agents, if performed), with interpretation and report — CPT codes covered for indications listed in the CPB.
1 Active Policy
AETNA-CPB-0396, Gastrointestinal Function: Selected Tests
Related Codes
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