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. 91572-R0

Gastroparesis
Testing and Treatment

C. Primary treatment of gastroparesis includes dietary manipulation and

administration of antiemetic and prokinetic agents. The following
treatments are NOT covered for the treatment of gastroparesis:
1. Gastric pacing (gastric pacemaker) and gastric electrical stimulation is
considered to be experimental and investigational (see medical policy
91468 Stimulation Therapy and Devices)
2. Use of Botulinum Toxin for the treatment of gastroparesis is considered to
be experimental and investigational (see medical policy 91455
Botulinum toxin)

III.

MEDICAL NECESSITY REVIEW

Required

IV.

Not Required

Not Applicable

APPLICATION TO PRODUCTS
Coverage is subject to members specific benefits. Group specific policy will
supersede this policy when applicable.

V.

HMO/EPO: This policy applies to insured HMO/EPO plans.

POS: This policy applies to insured POS plans.
PPO: This policy applies to insured PPO plans.
ASO: For self-funded plans, consult individual plan documents. If there is a conflict
between this policy and a self-funded plan document, the provisions of the plan document
will govern.
INDIVIDUAL: For individual policies, consult the individual insurance policy. If there is
a conflict between this medical policy and the individual insurance policy document, the
provisions of the individual insurance policy will govern.
MEDICARE: Coverage is determined by the Centers for Medicare and Medicaid Services
(CMS).
MEDICAID: Coverage is determined by the Michigan Medicaid Provider Manual and the
Michigan Medicaid Fee Schedule at: http://www.michigan.gov/mdch/0,1607,7-1322945_42542_42543_42546_42551-159815--,00.html.
MICHILD: For MICHILD members, this policy will apply unless MICHILD certificate of
coverage limits or extends coverage.

CODING INFORMATION
ICD9 Codes that may apply:
536.3
Gastroparesis
536.8
Dyspepsia and other specified disorders of function of stomach
536.9
Unspecified functional disorder of stomach 787.01 - 787.03 Nausea and
vomiting
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MEDICAL POLICY
No. 91572-R0

787.01
787.02

Gastroparesis
Testing and Treatment

Nausea with vomiting

Nausea alone

787.03 Vomiting alone

789.00 - 789.09 Abdominal pain
249.60
249.61
250.60
250.61
250.62
250.63

Secondary diabetes mellitus with neurological manifestations, not stated as

uncontrolled, or unspecified
Secondary diabetes mellitus with neurological manifestations, uncontrolled
Diabetes with neurological manifestations, type II or unspecified type, not
stated as uncontrolled
Diabetes with neurological manifestations, type I [juvenile type], not stated as
uncontrolled
Diabetes with neurological manifestations, type II or unspecified type,
uncontrolled
Diabetes with neurological manifestations, type I [juvenile type], uncontrolled

CPT/HCPCS Codes:
78264
Gastric emptying study
91020
Gastric motility (manometric) studies
43234
43235

43239
43245

43250

43251

Upper gastrointestinal endoscopy, simple primary examination (eg, with small

diameter flexible endoscope) (separate procedure)
Upper gastrointestinal endoscopy including esophagus, stomach, and either the
duodenum and/or jejunum as appropriate; diagnostic, with or without
collection of specimen(s) by brushing or washing (separate procedure)
Upper gastrointestinal endoscopy including esophagus, stomach, and either the
duodenum and/or jejunum as appropriate; with biopsy, single or multiple
Upper gastrointestinal endoscopy including esophagus, stomach, and either the
duodenum and/or jejunum as appropriate; with dilation of gastric outlet for
obstruction (eg, balloon, guide wire, bougie)
Upper gastrointestinal endoscopy including esophagus, stomach, and either the
duodenum and/or jejunum as appropriate; with removal of tumor(s), polyp(s),
or other lesion(s) by hot biopsy forceps or bipolar cautery
Upper gastrointestinal endoscopy including esophagus, stomach, and either the
duodenum and/or jejunum as appropriate; with removal of tumor(s), polyp(s),
or other lesion(s) by snare technique

Not Covered:
91132
Electrogastrography, diagnostic, transcutaneous
91133
Electrogastrography, diagnostic, transcutaneous; with provocative testing
91299
Unlisted diagnostic gastroenterology procedure - when billed for electronic
barostat or wireless capsule monitoring system (i.e. Smart pill)
(Explanatory notes must accompany claims billed with unlisted codes.)

See also:
Medical policy 91468 Stimulation Therapy and Devices
Medical policy 91455 Botulinum Toxin
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No. 91572-R0

VI.

Gastroparesis
Testing and Treatment

REFERENCES
1. American College of Gastroenterology - Gastroparesis. Accessed 1/11/2010
http://www.acg.gi.org/patients/gihealth/gastroparesis.asp
2. American Gastroenterological Association Medical Position Statement:
Diagnosis and Treatment of Gastroparesis Accessed 1/11/2010
http://www.gastro.org/userassets/Documents/02_Clinical_Practice/medical_position_statments/Gastropar
esisg_mps.pdf
3. Up-to-Date medical review service - Etiology and diagnosis of delayed gastric
emptying 6/19/2009. Accessed 1/11/2009
http://www.uptodate.com/online/content/topic.do?topicKey=gi_dis/8306&sele
ctedTitle=3%7E150&source=search_result#H23

AMA CPT Copyright Statement:

All Current Procedure Terminology (CPT) codes, descriptions, and other data are copyrighted by the
American Medical Association.
This document is for informational purposes only. It is not an authorization, certification, explanation of
benefits, or contract. 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 members plan in effect
as of the date services are rendered. Priority Healths medical policies are developed with the assistance
of medical professionals and are based upon a review of published and unpublished information including,
but not limited to, current medical literature, guidelines published by public health and health research
agencies, and community medical practices in the treatment and diagnosis of disease. Because medical
practice, information, and technology are constantly changing, Priority Health reserves the right to review
and update its medical policies at its discretion.
Priority Healths medical policies are intended to serve as a resource to the plan. They are not intended to
limit the plans ability to interpret plan language as deemed appropriate. Physicians and other providers
are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels
of care and treatment they choose to provide.
The name Priority Health and the term plan mean Priority Health, Priority Health Managed Benefits,
Inc., Priority Health Insurance Company and Priority Health Government Programs, Inc.

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