CG-MED-02 Esophageal pH Monitoring

This policy addresses esophageal pH monitoring (catheter-based or wireless) to evaluate esophageal acid exposure and symptom correlation in GERD. It is medically necessary for adults, children, or adolescents who can report symptoms when documenting abnormal acid exposure in endoscopy-negative patients being considered for antireflux surgery, evaluating suspected persistent reflux after antireflux surgery, or assessing refractory reflux with normal/equivocal endoscopy—performed after withholding antisecretory therapy for at least 1 week when confirming acid exposure, or while on therapy when scoring symptom–reflux correlation; it is not medically necessary when these criteria are not met.

"Esophageal pH monitoring is consideredmedically necessaryfor the following adults, children or adolescents who are able to report their symptoms in the following clinical situations:"