Aetna modified CPB 0396 for gastrointestinal function tests, effective November 23, 2025. Here's what changes for billing teams.
Aetna, a CVS Health company, updated its gastrointestinal function test coverage policy under CPB 0396 Aetna system. The policy now draws a hard line between covered GI diagnostics and those it considers experimental — and that line has direct consequences for CPT codes 91117, 78264, 78265, 78266, 72197, 74183, 0106U, 91112, 91132, 91133, and 0430U, plus HCPCS 0868T. If your practice bills GI motility studies, gastric emptying tests, or wireless capsule diagnostics for Aetna members, this coverage policy deserves your attention before claims go out the door.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Gastrointestinal Function: Selected Tests |
| Policy Code | CPB 0396 |
| Change Type | Modified |
| Effective Date | November 23, 2025 |
| Impact Level | High |
| Specialties Affected | Gastroenterology, Pediatric Surgery, Radiology, Nuclear Medicine |
| Key Action | Audit charge capture for CPT 91112, 0106U, 91132, and 91133 — these codes are now explicitly non-covered; remove them from Aetna claim submissions or expect denials |
Aetna Gastrointestinal Function Test Coverage Criteria and Medical Necessity Requirements 2025
Aetna's updated coverage policy covers three GI diagnostic tests when specific medical necessity criteria are met. Everything else on the list is experimental. Full stop.
Colonic manometry (CPT 91117) is medically necessary in a narrow, specific context: pediatric patients with refractory colonic motility or defecatory disorders, where the test guides surgical decision-making. This isn't a broadly covered diagnostic tool — it's covered when conservative options have failed and surgery is on the table for a child. If you're billing 91117 for adults or for non-surgical workups, don't expect coverage.
Radionuclide gastric emptying studies (CPT 78264, 78265, 78266) are covered for evaluation of gastrointestinal motility disorders and gastroparesis, including ICD-10 K31.84. These three codes cover solid, liquid, or combined studies — with or without small bowel and colon transit. This is a well-established diagnostic pathway, and Aetna's coverage here is consistent with clinical standards.
Magnetic resonance enterography (CPT 72197 and 74183) is covered to evaluate and monitor Crohn's disease (ICD-10 K50.00–K50.919) and other small bowel disorders. CPT 74183 covers abdomen without and with contrast; CPT 72197 covers pelvis without and with contrast. Both codes are covered when selection criteria are met — meaning you need the right diagnosis codes attached and documentation supporting the clinical indication.
Prior authorization requirements are not explicitly detailed in CPB 0396, but Aetna's standard plan utilization management rules apply. Check prior auth requirements at the plan level before scheduling advanced imaging or manometry studies for Aetna members.
The real issue here is what falls into the experimental bucket. Nine distinct tests — including some that GI practices use routinely — are now explicitly non-covered. That creates real claim denial risk for practices that haven't updated their billing guidelines to reflect this policy.
Aetna Gastrointestinal Function Test Exclusions and Non-Covered Indications 2025
Aetna considers nine GI diagnostic approaches experimental, investigational, or unproven under CPB 0396. "Experimental" in payer language means no reimbursement, full stop — and these are specifically named, not just implied.
3D high-resolution manometry for esophago-gastric junction contractility quantification is out. This is relevant if your GI team uses advanced manometry setups beyond standard esophageal pressure measurement.
Body surface gastric mapping (Gastric Alimetry), billed under HCPCS 0868T, is non-covered for all indications. This is a newer technology that hasn't cleared Aetna's evidence threshold. If your practice recently added this service, pull it from Aetna charge capture.
Electrogastrography — CPT 91132 (transcutaneous) and 91133 (transcutaneous with provocative testing) — is explicitly experimental. These codes have no covered pathway under this policy.
The gastric emptying breath test (GEBT), billed as CPT 0106U, is non-covered for gastroparesis and all other indications. This is a significant callout. Some practices use GEBT as an alternative to radionuclide gastric emptying studies — particularly in settings without nuclear medicine. Aetna won't pay for it, regardless of how it's documented.
High-resolution esophageal pressure topography (HREPT) is experimental. This is distinct from standard esophageal manometry — don't assume coverage carries over.
The IgG antibody blood test for IBS food triggers (e.g., Biomerica inFoods IBS) is non-covered. This includes any similar panel marketed for IBS dietary management.
The Malabsorption Evaluation Panel from Mayo Clinic Laboratories, billed as CPT 0430U, is experimental. This covers quantitative evaluation of alpha-1 antitrypsin, calprotectin, pancreatic elastase, and reducing substances for intestinal dysbiosis, IBS, malabsorption, or small intestinal bacterial overgrowth — and all other indications.
The PillSense System for upper GI bleeding detection has no covered pathway here.
The SmartPill GI Monitoring System (wireless capsule, CPT 91112) for gastroparesis, chronic constipation, and all other gastric or intestinal motility evaluations is experimental. Aetna specifically cites inadequate published evidence of its diagnostic performance and clinical utility over conventional gastric emptying measurement.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Colonic motility/defecatory disorders in children — surgical decision-making | Covered | CPT 91117 | Pediatric patients only; must be guiding surgical planning |
| GI motility disorders and gastroparesis — radionuclide study | Covered | CPT 78264, 78265, 78266 | Use ICD-10 K31.84 for gastroparesis; verify plan-level prior auth |
| Crohn's disease and small bowel disorders — MR enterography | Covered | CPT 72197, 74183 | ICD-10 K50.00–K50.919; selection criteria required |
| Gastroparesis — gastric emptying breath test (GEBT) | Experimental | CPT 0106U | Not covered for any indication |
| Gastric motility/gastroduodenal disorders — body surface gastric mapping | Experimental | HCPCS 0868T | Not covered for any indication |
| Electrogastrography — any indication | Experimental | CPT 91132, 91133 | Explicitly non-covered |
| Gastroparesis / chronic constipation — SmartPill wireless capsule | Experimental | CPT 91112 | Inadequate evidence per Aetna; not covered for any indication |
| Intestinal malabsorption, IBS, dysbiosis — Mayo Malabsorption Panel | Experimental | CPT 0430U | Not covered for any indication |
| IBS food triggers — IgG antibody testing | Experimental | Not separately coded in CPB | No covered pathway |
| Upper GI bleeding — PillSense | Experimental | Not separately coded in CPB | No covered pathway |
| Esophago-gastric junction contractility — 3D HR manometry | Experimental | Not separately coded in CPB | No covered pathway |
| Esophageal pressure topography (HREPT) | Experimental | Not separately coded in CPB | No covered pathway |
Aetna Gastrointestinal Function Test Billing Guidelines and Action Items 2025
| # | Action Item |
|---|---|
| 1 | Pull CPT 0106U from your Aetna charge capture now. The gastric emptying breath test has no covered indication under CPB 0396 as of November 23, 2025. If your GI practice uses GEBT as a gastroparesis diagnostic, you need a clinical pathway shift for Aetna members — switch to the covered radionuclide gastric emptying study (CPT 78264, 78265, or 78266) where appropriate. |
| 2 | Remove CPT 91112 (SmartPill) from Aetna claims immediately. Wireless capsule gastric monitoring is experimental under this policy. Claims using 91112 for Aetna members will deny. Document this in your payer-specific billing guidelines so your coders don't inadvertently submit it. |
| 3 | Flag CPT 91132 and 91133 as non-covered for Aetna. Electrogastrography — both standard and with provocative testing — is experimental. If these codes are in your charge capture for GI motility workups, remove them from Aetna submissions and update your billing guidelines accordingly. |
| 4 | Tighten diagnosis code pairing for covered codes. For CPT 78264, 78265, and 78266, make sure K31.84 (gastroparesis) or an appropriate motility disorder code is attached. For CPT 72197 and 74183, confirm K50.xx (Crohn's disease) or a documented small bowel disorder is in the record before billing. Missing or mismatched ICD-10 codes are the most common reason covered claims still get denied. |
| 5 | Restrict CPT 91117 billing to pediatric surgical cases. Colonic manometry is covered only for children with refractory colonic motility or defecatory disorders when the study is guiding surgical decision-making. If your practice bills 91117 for adult patients or general GI workups, those claims will not meet Aetna's medical necessity standard under this policy. |
| 6 | Pull HCPCS 0868T from Aetna billing workflows. Body surface gastric mapping (Gastric Alimetry) is non-covered for all indications. If this service was recently added to your GI practice, it has no reimbursement pathway with Aetna. |
| 7 | Check plan-level prior authorization rules. CPB 0396 doesn't publish a specific prior auth list, but Aetna's utilization management programs often require prior authorization for advanced imaging and specialized motility studies. Confirm requirements at the specific plan level before scheduling CPT 72197, 74183, or 91117 for Aetna members. |
| 8 | Audit claims submitted on or after the effective date of November 23, 2025. If your practice submitted claims for any non-covered codes after this date, pull those claims and assess denial exposure. If you're uncertain how to scope the audit, loop in your billing consultant before the end of year. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Gastrointestinal Function Tests Under CPB 0396
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Type | Description |
|---|---|---|
| 91117 | CPT | Colon motility (manometric) study, minimum 6 hours continuous recording (including provocation tests) — covered for indications listed in CPB |
| 72197 | CPT | Magnetic resonance imaging, pelvis; without contrast material(s), followed by contrast — covered if selection criteria are met |
| 74183 | CPT | Magnetic resonance imaging, abdomen; without contrast material(s) followed by contrast — covered if selection criteria are met |
| 78264 | CPT | Gastric emptying imaging study (e.g., solid, liquid, or both) — covered if selection criteria are met |
| 78265 | CPT | Gastric emptying imaging study; with small bowel transit — covered if selection criteria are met |
| 78266 | CPT | Gastric emptying imaging study; with small bowel and colon transit, multiple days — covered if selection criteria are met |
Not Covered / Experimental Codes
| Code | Type | Description | Reason |
|---|---|---|---|
| 0106U | CPT | Gastric emptying, serial collection of 7 timed breath specimens, non-radioisotope carbon-13 (13C) — gastric emptying breath test | Experimental for gastroparesis and all other indications |
| 0430U | CPT | Gastrointestinal malabsorption evaluation of alpha-1-antitrypsin, calprotectin, pancreatic elastase — Mayo Malabsorption Panel | Experimental for intestinal dysbiosis, IBS, malabsorption, SIBO, and all other indications |
| 0779T | CPT | Gastrointestinal myoelectrical activity study, stomach through colon, with interpretation and report | Not covered for indications listed in CPB |
| 91112 | CPT | Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation — SmartPill | Experimental; inadequate evidence over conventional gastric emptying measurement |
| 91132 | CPT | Electrogastrography, diagnostic, transcutaneous | Experimental for all indications |
| 91133 | CPT | Electrogastrography, diagnostic, transcutaneous; with provocative testing | Experimental for all indications |
| 0868T | HCPCS | High-resolution gastric electrophysiology mapping with simultaneous patient-symptom profiling — Gastric Alimetry / body surface gastric mapping | Experimental for all indications |
Key ICD-10-CM Diagnosis Codes
| Code | Description |
|---|---|
| K31.84 | Gastroparesis |
| K30 | Functional dyspepsia |
| K21.0 | Gastro-esophageal reflux disease with esophagitis |
| K21.9 | Gastro-esophageal reflux disease without esophagitis |
| K31.0–K31.9 | Other diseases of stomach and duodenum |
| K50.00–K50.919 | Crohn's disease (regional enteritis) |
| K58.0–K58.9 | Irritable bowel syndrome |
| K59.0–K59.9 | Constipation |
| K57.0–K57.9 | Diverticular disease of small intestine |
| K90.0–K90.2 | Intestinal malabsorption |
| K63.8211–K63.829 | Intestinal microbial overgrowth |
| C17.0–C17.9 | Malignant neoplasm of small intestine |
| K31.A0–K31.A29 | Gastric intestinal metaplasia |
| K20.0–K31.9 | Diseases of esophagus, stomach and duodenum (range) |
| K55.011–K64.9 | Diseases of intestines (range) |
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