CommercialCoverageMedium impact
Gastrointestinal Manometry (CPB 0616, reviewed 2026-09-03)
Aetna·Gastroenterology, Internal Medicine, General Surgery +1 more·Medical Policy
We identified it
Oct 4, 2026
Summary
Aetna has updated its gastrointestinal manometry policy (CPB 0616) effective immediately, establishing specific medical necessity criteria for four types of manometry procedures and clarifying which indications are not covered. Billing teams must now validate that claims meet strict documentation requirements (e.g., failed conservative management, normal/equivocal gastric emptying tests) before submission, as claims not meeting these criteria will be denied as experimental/investigational.
Action Required
IMMEDIATE: Billing team must implement the following controls in the billing system for all Aetna claims: (1) For CPT 91010/91013 (esophageal manometry): Require documented dysphagia, achalasia, rumination syndrome, PPI-refractory chest pain, or anti-reflux surgery evaluation. Do NOT cover diaphragmatic flutter disease or chronic cough indications. (2) For CPT 91022 (antroduodenal/duodenal manometry): Require evidence of dyspepsia/gastroparesis/chronic intestinal pseudo-obstruction AND normal or equivocal gastric emptying AND failed conservative management (e.g., PPI twice-daily, prokinetics). Deny if gastric emptying is delayed or abnormal. (3) For CPT 91117 (colonic motility): Cover only for children with refractory colonic motility/defecatory disorders requiring surgical guidance. (4) For CPT 91120/91122/91124/91125 (anorectal manometry): Require chronic constipation with failed laxatives OR fecal incontinence with 3+ months failed conservative management AND negative colonoscopy/sigmoidoscopy. Update all claim submission templates and denial logic. Any claim lacking required documentation should be denied as experimental/investigational per policy. Providers must submit supporting documentation (gastric emptying study results, conservative treatment records, endoscopy reports) with claims or risk denial.