CommercialCoverageHigh impact
Gastrointestinal Function: Selected Tests (CPB 0396, reviewed 2026-07-09)
Aetna·Gastroenterology, Pediatrics, Internal Medicine +3 more·Medical Policy
Effective date
Jul 9, 2026
We identified it
Aug 17, 2026
Summary
Aetna updated its gastrointestinal function testing policy (CPB 0396, effective 2026-07-09) to clarify coverage and non-coverage determinations for 10 diagnostic tests. Key changes: Radionuclide gastric emptying studies, colonic manometry (for pediatric refractory cases), and MR enterography remain covered; however, SmartPill GI monitoring, gastric emptying breath tests, body surface gastric mapping, electrogastrography, high-resolution manometry, IgG food trigger testing, malabsorption panels, and PillSense are now classified as experimental/investigational and NOT covered. Billing teams must immediately deny or refund claims for non-covered codes.
Action Required
By 2026-07-09, billing team must immediately: (1) Configure billing system to DENY all claims for non-covered CPT/HCPCS codes (0779T, 91112, 0868T, 0106U, 0430U, 0977T, 91132, 91133) with denial reason 'Experimental/Investigational per Aetna CPB 0396'; (2) Update claim scrubbing rules to flag any claims submitted for these codes for manual review and denial; (3) For claims already paid for non-covered codes, initiate refund/reversal process with patient communication; (4) Ensure providers are notified via bulletin that these tests are non-covered and require patient financial responsibility forms; (5) Maintain covered codes (91117, 78264, 78265, 78266, 72197, 74183) in billing system as covered-if-medically-necessary with appropriate ICD-10 matching. Failure to implement denial rules will result in improper payments and overpayment recovery demands from Aetna.