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Medical & Coding Policies
Provider Network Application
Out-of-State & Non-Network
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DESCRIPTIONAcid reflux is the cause of heartburn, acid regurgitation peptic esophagitis, and Barrett's esophagus, and a cause of esophageal stricture, some cases of asthma, posterior laryngitis, chronic cough, dental erosions, chronic hoarseness, pharyngitis subglottic stenosis or stricture, nocturnal choking, and recurrent pneumonia. Gastroesophageal reflux disease (GERD) is usually diagnosed by clinical history and endoscopy, and is treated empirically with a trial of medical management.The esophageal monitoring is done through the use of a tube with a pH electrode attached to its tip, which is then passed to almost exactly 5 cm above the upper margin of the lower esophageal sphincter (LES). The electrode is attached to a data logger worn on a waist belt or shoulder strap. Every instance of acid reflux as well as its duration and pH is recorded, indicating gastric acid reflux over a 24-hour period. More recently, a catheter-free, temporarily implanted device (BravoTM pH Monitoring System, Medtronic®) has been approved by the U.S. Food and Drug Administration (FDA) for the purposes of esophageal monitoring. Using endoscopic or manometric guidance, the capsule is temporarily implanted in the esophageal mucosa using a pin. The capsule records pH levels for up to 48 hours and transmits them via radio frequency telemetry to a receiver worn in the patient’s belt. Data from the recorder are uploaded to a computer for analysis by a nurse or doctor. Another technology closely related to pH monitoring is impedance-pH monitoring, which incorporates pH monitoring with measurement of impedance, a method of measuring reflux of liquid or gas of any pH. Multiple electrodes are placed along the length of the esophageal catheter. The impedance pattern detected can determine the direction of flow and the substance (liquid or gas). Impedance monitoring is able to identify reflux events in which the liquid is only slightly acidic or non-acidic.
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POLICYEsophageal pH monitoring using a wireless or catheter-based system may be considered medically necessary for the following clinical indications in adults and children or adolescents able to report symptoms*:
24-hour catheter-based esophageal pH monitoring may be considered medically necessary in infants or children who are unable to report or describe symptoms of reflux with:
24-hour catheter-based impedance-pH monitoring is considered not medically necessary. *Esophageal pH monitoring systems should be used in accordance with FDA-approved indications and age ranges.
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POLICY EXCEPTIONSFor the Federal Employee Program (FEP) subscribers only, devices approved by the U.S. Food and Drug Administration (FDA) may not be considered investigational, and thus these devices may be assessed only on the basis of their medical necessity.
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POLICY GUIDELINESThe endoscopy performed for placing the BRAVO capsule is not reimbursed separately. (added 11/2003) The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
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POLICY HISTORY9/1993: Approved by Medical Policy Advisory Committee (MPAC)5/2000: Comprehensive revision approved by MPAC 4/26/2002: Type of Service and Place of Service deleted 11/2003: Reviewed by MPAC, no changes in coverage criteria, BRAVOTM pH Monitoring System covered at current reimbursement guidelines, "Description" section revised to be consistent with BCBSA, FEP exception added 2/13/2004: Code Reference section updated 3/22/2005: Code Reference section updated, CPT code 91032 deletion date of 12/31/2004 and Note "See CPT code 91034-91035" added, CPT code 91033 description revised, deletion date of 12/31/2004, and Note "See CPT code 91034-91035" added, CPT code 91034, 91035 with effective date of 1/1/2005 added 8/18/2006: Policy section re-written for clarity and 48-hour wireless monitoring changed from investigational to not medically necessary. 12/19/2007: 91035 moved to non-covered table. 1/10/2008: Policy reviewed, no changes 9/22/2008: Annual ICD-9 updates effective 10-1-2008 applied 12/17/2008: Policy reviewed, no changes 9/29/2009: Code Reference section updated. New ICD-9 diagnosis codes 784.42, 784.43 and 784.44 added to covered table. Description revised for ICD-9 code 784.49. 06/03/2010: Policy statement updated to indicate that wireless monitoring may be considered medically necessary in patients who meet criteria for testing but cannot tolerate catheter-based testing. Wireless monitoring in all other situations is considered not medically necessary. The time interval in the policy statement for wireless monitoring was changed from “48-hour” to “48- to 96-hour.” Other policy statements unchanged. Deleted outdated references from the Sources section. Due to the policy statement change, CPT code 91035 was moved from non-covered to covered. 01/24/2011: Added ICD-9 code 530.81 to the Covered Codes table. 06/22/2011: Policy description updated to add information regarding impedance-pH monitoring. Added the following policy statement: 24-hour catheter-based impedance-pH monitoring is considered not medically necessary. 07/12/2012: Added wireless pH monitoring to the first medically necessary policy statement. Deleted the following policy statement: 1) 48- to 96-hour, catheter-free, wireless esophageal monitoring may be considered medically necessary for use in esophageal pH monitoring for patients who are unable to tolerate catheter-based testing (and unable to complete this testing) but meet the criteria listed above for monitoring. 2) 48- to 96-hour, catheter-free, wireless esophageal monitoring is considered not medically necessary for the use in esophageal pH monitoring, except under the specific circumstances noted. Added monitoring must be done in accordance with FDA approved indications and age ranges to policy statement. Added the following ICD-9 codes to the Covered Codes table: 427.89, 476.0,507.0, 770.81-770.89, 780.57, 784.99, 786.03, 786.07, and 786.1. Added a Non-Covered Codes table and added 91037 and 91038 as non-covered procedures as these codes are used to report impedance-pH monitoring.
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SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.20
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CODE REFERENCEThis is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. Covered Codes
This is not an all-inclusive list of non-covered procedure codes. The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure. Non-Covered Codes
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