Gastrointestinal Manometry

Aetna covers antroduodenal manometry only for dyspepsia, gastroparesis, or chronic intestinal pseudo‑obstruction with unexplained upper GI symptoms when gastric emptying is normal or equivocal and severe symptoms persist despite empiric conservative therapy; it also covers anorectal manometry (including rectal sensation/tone/compliance), high‑resolution esophageal manometry for dysphagia (including achalasia, rumination, PPI‑refractory chest pain) and pre–anti‑reflux evaluation, and colonic manometry to guide surgery in children with refractory colonic motility/defecatory disorders (CPTs 91010, +91013, 91117, 91120, 91122 when selection criteria are met). Antroduodenal or colonic manometry for other indications, MRI capsule‑marker methods for whole‑gut transit, and use of antroduodenal manometry when gastric emptying or myoelectrical testing is already abnormal are considered experimental/investigational and not covered.

"When applicable, documentation of relevant prior diagnostic tests (e."