Esophageal pH Monitoring

This policy covers esophageal pH monitoring (catheter-based, wireless/pH capsule, and impedance-pH testing) to quantify esophageal acid exposure and reflux episodes. It is indicated for adults and symptom-reporting children/adolescents and for evaluation of refractory GERD (including pre- or post-antireflux surgery, extraesophageal symptoms such as chronic cough/laryngitis or suspected reflux-induced asthma, and infants/children unable to report symptoms with apnea/bradycardia/recurrent aspiration), but testing must follow FDA‑approved device indications/age ranges, is not first-line before empirical PPI therapy, is limited to ~24 hours for catheters or up to 96 hours for wireless capsules, and has imperfect diagnostic performance and limited evidence of clinical utility.

"Esophageal pH monitoring (catheter or wireless) is medically necessary for adults and for children/adolescents who are able to report symptoms."