CG-SURG-70 Gastric Electrical Stimulation

This policy addresses gastric electrical stimulation (GES) devices, including implantation and removal, for gastroparesis-related nausea and vomiting. GES is medically necessary for chronic, intractable nausea/vomiting due to severe diabetic or idiopathic gastroparesis when the patient has failed, cannot tolerate, or has contraindications to prokinetic and antiemetic medications and has delayed gastric emptying confirmed by standard solid-meal scintigraphy; removal is medically necessary for device-related complications (e.g., obstruction, gastric perforation, infection, lead dislodgement/disruption, or generator site pain). GES is not medically necessary for any other indication (including obesity), and revision, replacement, or removal is not covered unless the above criteria are met.

"Gastric electrical stimulation is consideredmedically necessaryin the treatment of chronic intractable nausea and vomiting secondary to severe gastroparesis of diabetic or idiopathic etiology when ..."