HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
M-23-021
Topic:
Esophageal pH Monitoring
Section:
Diagnostic Medical
Effective Date:
November 27, 2017
Issued Date:
October 1, 2018
Last Revision Date:
September 2018
Annual Review:
September 2018
 
 

 

Esophageal pH monitoring using wired or wireless devices can record the pH of the lower esophagus for a period of one (1) to several days. These devices may aid in the diagnosis of gastroesophageal reflux disease (GERD) in patients who have an uncertain diagnosis after clinical evaluation and endoscopy.

 

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Esophageal pH monitoring may be considered medically necessary in adults, children, or adolescents capable to report symptoms for the following:

  • Documentation of abnormal acid exposure in endoscopy-negative  individual being considered for surgical anti-reflux repair; or
  • Evaluation of  individual after anti-reflux surgery who are suspected of having ongoing abnormal reflux; or
  • Evaluation of  individual with either normal or equivocal endoscopic findings and reflux symptoms that are refractory to proton pump inhibitor (PPI) therapy; or
  • Evaluation of refractory reflux in  individual with chest pain after cardiac evaluation and after a four (4)-week trial of PPI therapy; or  
  • Evaluation of suspected otolaryngologic manifestations of GERD (laryngitis, pharyngitis, chronic cough) in individuals who have failed to respond to at least four (4)-weeks of PPI therapy; or
  • Evaluation of concomitant GERD in with adult-onset, non-allergic asthma suspected of having reflux-induced asthma.

Twenty-four (24) hour catheter-based esophageal pH monitoring may be considered medically necessary in infants or children unable to report or describe symptoms of reflux with:

  • Unexplained apnea; or
  • Bradycardia; or
  • Refractory coughing, wheezing or recurrent aspiration; or
  • Persistent or recurrent laryngitis; or
  • Persistent or recurrent pneumonia.

Esophageal pH monitoring is considered not medical necessary when performed for indications other than those listed above.

91034

91035

 

 

 

 

 


Multichannel intraluminal impedance-pH monitoring is considered not medically necessary.

91037

91038

 

 

 

 

 


Covered Diagnosis Codes for Procedure Codes 91034 and 91035

G47.30

G47.31

G47.32

G47.33

J31.2

J37.0

J45.20

J45.21

J45.22

J45.30

J45.31

J45.32

J45.40

J45.41

J45.42

J45.50

J45.51

J45.52

J45.901

J45.902

J45.909

J45.990

J45.991

J45.998

J69.0

K21.0

K21.9

P28.0

P28.10

P28.11

P28.19

P28.2

P28.3

P28.4

P28.5

P28.81

P28.89

P28.9

R00.1

R05

R06.1

R06.2

R06.81

R07.89

 

 

 

 

 


Place of Service: Outpatient

Esophageal pH monitoring is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.




    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.