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MEDICAL POLICY

No. 91572-R0
GASTROPARESIS TESTING AND TREATMENT
Effective Date: March 25, 2010
Date Of Origin: February 10, 2010

I.

Review Dates: 2/10
Status: New

DESCRIPTION
Gastroparesis (delayed gastric emptying) is a digestive disorder in which the
motility of the stomach is either abnormal or absent. Clinical symptoms that
suggest gastroparesis include nausea, vomiting, and postprandial abdominal
fullness.
The diagnosis of gastroparesis is based on the presence of appropriate
symptoms/signs, delayed gastric emptying, and the absence of an obstructing
structural lesion in the stomach or small intestine.
Primary treatment of gastroparesis includes dietary manipulation and administration of
antiemetic and prokinetic agents.

II.

POLICY/CRITERIA
A. The following are covered for the purpose of evaluation and diagnosis of
gastroparesis:
1. Upper Endoscopy - to confirm the presence of gastric stasis by the finding
of retained food after an overnight period of fasting. Also to exclude
mechanical obstruction or mucosal disease as a cause of impaired gastric
emptying
2. Gastric emptying scintigraphy (GES)
3. Gastroduodenal manometry – for patients who have evidence of gastric
stasis by a scintigraphic study without an identifiable cause
B. The following are NOT covered for evaluation and diagnosis of
gastroparesis as they are considered to be experimental and
investigational:
1.
2.
3.
4.

Cutaneous electrogastrogram (EGG)
Electronic barostat
MRI
Wireless capsule monitoring system (i.e. Smart pill)

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MEDICAL POLICY No. INDIVIDUAL: For individual policies. consult individual plan documents. MEDICAL NECESSITY REVIEW Required IV.gov/mdch/0.html.00. Use of Botulinum Toxin for the treatment of gastroparesis is considered to be experimental and investigational (see medical policy 91455 – Botulinum toxin) III. the provisions of the plan document will govern. POS: This policy applies to insured POS plans.8 Dyspepsia and other specified disorders of function of stomach 536. ™ ™ ™ ™ ™ ™ ™ ™ V. MICHILD: For MICHILD members. CODING INFORMATION ICD9 Codes that may apply: 536. Gastric pacing (gastric pacemaker) and gastric electrical stimulation is considered to be experimental and investigational (see medical policy 91468 – Stimulation Therapy and Devices) 2.03 Nausea and vomiting Page 2 of 4 . HMO/EPO: This policy applies to insured HMO/EPO plans. PPO: This policy applies to insured PPO plans.1607. MEDICARE: Coverage is determined by the Centers for Medicare and Medicaid Services (CMS).9 Unspecified functional disorder of stomach 787. The following treatments are NOT covered for the treatment of gastroparesis: 1. Primary treatment of gastroparesis includes dietary manipulation and administration of antiemetic and prokinetic agents. If there is a conflict between this medical policy and the individual insurance policy document.3 Gastroparesis 536. the provisions of the individual insurance policy will govern.787.michigan. this policy will apply unless MICHILD certificate of coverage limits or extends coverage. consult the individual insurance policy.7-1322945_42542_42543_42546_42551-159815--. MEDICAID: Coverage is determined by the Michigan Medicaid Provider Manual and the Michigan Medicaid Fee Schedule at: http://www. ASO: For self-funded plans. 91572-R0 Gastroparesis Testing and Treatment C.01 . Not Required Not Applicable APPLICATION TO PRODUCTS Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable. If there is a conflict between this policy and a self-funded plan document.

02 Gastroparesis Testing and Treatment Nausea with vomiting Nausea alone 787.09 Abdominal pain 249. not stated as uncontrolled Diabetes with neurological manifestations.61 250. and either the duodenum and/or jejunum as appropriate. with provocative testing 91299 Unlisted diagnostic gastroenterology procedure . with dilation of gastric outlet for obstruction (eg. not stated as uncontrolled Diabetes with neurological manifestations. stomach.62 250. bougie) Upper gastrointestinal endoscopy including esophagus. stomach.60 250. type I [juvenile type].60 249. uncontrolled CPT/HCPCS Codes: 78264 Gastric emptying study 91020 Gastric motility (manometric) studies 43234 43235 43239 43245 43250 43251 Upper gastrointestinal endoscopy. diagnostic.MEDICAL POLICY No. polyp(s). and either the duodenum and/or jejunum as appropriate. type II or unspecified type.61 250. uncontrolled Diabetes with neurological manifestations. stomach. with removal of tumor(s). Smart pill) (Explanatory notes must accompany claims billed with unlisted codes. transcutaneous 91133 Electrogastrography. stomach. 91572-R0 787. with or without collection of specimen(s) by brushing or washing (separate procedure) Upper gastrointestinal endoscopy including esophagus. and either the duodenum and/or jejunum as appropriate. and either the duodenum and/or jejunum as appropriate.63 Secondary diabetes mellitus with neurological manifestations. and either the duodenum and/or jejunum as appropriate.00 . with small diameter flexible endoscope) (separate procedure) Upper gastrointestinal endoscopy including esophagus.e. or other lesion(s) by snare technique Not Covered: 91132 Electrogastrography. with removal of tumor(s). or other lesion(s) by hot biopsy forceps or bipolar cautery Upper gastrointestinal endoscopy including esophagus. or unspecified Secondary diabetes mellitus with neurological manifestations. with biopsy. guide wire. diagnostic. stomach.03 Vomiting alone 789. transcutaneous. uncontrolled Diabetes with neurological manifestations.) See also: Medical policy 91468 – Stimulation Therapy and Devices Medical policy 91455 – Botulinum Toxin Page 3 of 4 . simple primary examination (eg. type II or unspecified type. balloon. polyp(s). type I [juvenile type]. not stated as uncontrolled.01 787. diagnostic. single or multiple Upper gastrointestinal endoscopy including esophagus.when billed for electronic barostat or wireless capsule monitoring system (i.789.

91572-R0 VI. Priority Health’s medical policies are intended to serve as a resource to the plan. Accessed 1/11/2010 http://www. Up-to-Date medical review service . Priority Health’s medical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including.asp 2. It is not an authorization. and other data are copyrighted by the American Medical Association.gi. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with the terms of the member’s plan in effect as of the date services are rendered. but not limited to. Accessed 1/11/2009 http://www.acg. certification. descriptions. Priority Health reserves the right to review and update its medical policies at its discretion. Inc. Priority Health Managed Benefits. They are not intended to limit the plan’s ability to interpret plan language as deemed appropriate. and levels of care and treatment they choose to provide. information.. Physicians and other providers are solely responsible for all aspects of medical care and treatment.MEDICAL POLICY No.Gastroparesis.org/patients/gihealth/gastroparesis. or contract. quality. Priority Health Insurance Company and Priority Health Government Programs. Gastroparesis Testing and Treatment REFERENCES 1. and community medical practices in the treatment and diagnosis of disease. American Gastroenterological Association Medical Position Statement: Diagnosis and Treatment of Gastroparesis – Accessed 1/11/2010 http://www. explanation of benefits.gastro. The name “Priority Health” and the term “plan” mean Priority Health. and technology are constantly changing. Because medical practice.Etiology and diagnosis of delayed gastric emptying – 6/19/2009. Inc.org/userassets/Documents/02_Clinical_Practice/medical_position_statments/Gastropar esisg_mps.do?topicKey=gi_dis/8306&sele ctedTitle=3%7E150&source=search_result#H23 AMA CPT Copyright Statement: All Current Procedure Terminology (CPT) codes.uptodate. Page 4 of 4 . guidelines published by public health and health research agencies. including the type. This document is for informational purposes only.pdf 3.com/online/content/topic. American College of Gastroenterology . current medical literature.