CommercialPrior AuthHigh impact
Gastrointestinal Manometry (CPB 0616, reviewed 2026-02-25)
Aetna·Gastroenterology, Internal Medicine, General Surgery +1 more·Medical Policy
Effective date
Feb 25, 2026
We identified it
Aug 17, 2026
Summary
Aetna updated its gastrointestinal manometry policy (CPB 0616) effective 2026-02-25, clarifying which manometry procedures are medically necessary versus experimental. The policy now specifies strict criteria for antroduodenal, anorectal, colonic, and esophageal manometry coverage, requiring prior authorization review for claims that don't meet documented prerequisites (e.g., failed conservative management, normal gastric emptying studies, negative endoscopy).
Action Required
By 2026-02-25: Billing and authorization teams must implement the following: (1) Update billing software to require prior authorization for CPT 91010, 91013, 91022, 91117, 91120, 91122, 91124, and 91125 when billed to Aetna. (2) Add automated compliance checks in the system to deny or flag claims that lack documented evidence of: antroduodenal manometry only if gastric emptying is normal/equivocal AND conservative management failed AND symptoms documented as severe; anorectal manometry only if constipation failed to respond to laxatives OR fecal incontinence failed 3+ months conservative measures AND negative endoscopy documented; colonic motility only if pediatric refractory disorders requiring surgical guidance; esophageal manometry only for dysphagia/achalasia/reflux surgery evaluation. (3) Providers must include required documentation on encounter forms: prior conservative treatment attempts, test results (gastric emptying, endoscopy), symptom severity, and duration of symptoms. (4) Reject or request additional documentation for experimental indications (MRI capsule markers, pharyngeal impedance manometry, diaphragmatic flutter evaluation, chronic cough evaluation). Failure to comply will result in claim denials and possible recovery actions.