Esophageal pH monitoring using a catheter or wireless-based system may be considered medically necessary for the following clinical indications in adults and children or adolescents able to report symptoms.a
Documentation of abnormal acid exposure in endoscopy-negative individuals being considered for surgical antireflux repair;
Evaluation of individuals after antireflux surgery who are suspected of having ongoing abnormal reflux;
Evaluation of individuals with either normal or equivocal endoscopic findings and reflux symptoms refractory to proton pump inhibitor therapy;
Evaluation of refractory reflux in individuals with chest pain after cardiac evaluation and after a 1-month trial of proton pump inhibitor therapy;
Evaluation of suspected otolaryngologic manifestations of gastroesophageal reflux disease (ie, laryngitis, pharyngitis, chronic cough) in individuals who have failed to respond to at least 4 weeks of proton pump inhibitor therapy;
Evaluation of concomitant gastroesophageal reflux disease in individuals with adult-onset, nonallergic asthma suspected of having reflux-induced asthma.
Twenty-four-hour catheter-based esophageal pH monitoring may be considered medically necessary in infants or children who are unable to report or describe symptoms of reflux with:
unexplained apnea;
bradycardia;
refractory coughing or wheezing, stridor, or recurrent choking (aspiration);
persistent or recurrent laryngitis; and
recurrent pneumonia.
Twenty-four-hour catheter-based impedance pH monitoring may be considered investigational in individuals with established gastroesophageal reflux disease (GERD) on proton pump inhibitor (PPI) therapy, whose symptoms have not responded adequately to twice-daily PPI therapy, in order to define refractory GERD.
The above medically necessary indications are in accordance with the policy guidelines (see below), the 2021 American College of Gastroenterology and the 2022 American Gastroenterological Association (AGA) clinical guidelines on the clinical use of esophageal physiologic testing (see Supplemental Information).
a Esophageal pH monitoring systems should be used in accordance with U.S. Food and Drug Administration-approved indications and age ranges.
