About this policy
CMS National Coverage Determination | ncd_id=191 | manual_section=100.4 | coverage_level_code=1 | national_coverage_type=True | under_review=False | lab_ncd=False
Coverage indications
Esophageal manometry is covered under Medicare where it is determined to be reasonable and necessary for the individual patient.
Documentation requirements
Item/Service Description: The major use of esophageal manometry is to measure pressure within the esophagus to assist in the diagnosis of esophageal pathology including aperistalsis, spasm, achalasia, esophagitis, esophageal ulcer, esophageal congenital webs, diverticuli, scleroderma, hiatus hernia, congenital cysts, benign and malignant tumors, hypermobility, hypomobility, and extrinsic lesions. Esophageal manometry is mostly used in difficult diagnostic cases and as an adjunct to X- rays and direct visualization of the esophagus (endoscopy) through the fiberscope. Benefit Categories: 20 - Diagnostic Tests (other)
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
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