Gastrointestinal Manometry — CPB 0616 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0616 governing gastrointestinal manometry coverage, effective February 27, 2026. Here's what billing teams need to know before submitting claims for CPT 91010, 91022, 91117, 91120, 91122, 91124, and 91125.

This update to the Aetna gastrointestinal manometry coverage policy clarifies medical necessity thresholds across four distinct procedure categories — esophageal, antroduodenal, colonic, and anorectal manometry. The policy also expands the list of experimental and non-covered indications, which is where your claim denial risk lives. If your practice bills these codes for gastroenterology, colorectal surgery, or pediatric GI, read this before February 27, 2026.

Quick-Reference Table

Aetna Gastrointestinal Manometry Coverage Criteria and Medical Necessity Requirements 2026

The real challenge with gastrointestinal manometry billing is that Aetna draws hard lines between covered and non-covered indications — and those lines run through specific clinical conditions, failed treatment histories, and diagnostic prerequisites. Submitting the right CPT code isn't enough. Your documentation has to prove the clinical pathway.

Here's how Aetna defines medical necessity across the four procedure types under CPB 0616.

Antroduodenal manometry (CPT 91022) is covered for members with dyspepsia, gastroparesis (ICD-10 K31.84), or chronic intestinal pseudo-obstruction (ICD-10 K56.0–K56.7) who have unexplained upper GI symptoms like nausea or vomiting. Two conditions must also be true: gastric emptying must be normal or equivocal, and severe symptoms must persist despite empiric therapeutic trials. Those trials include at least twice-daily proton pump inhibitors and prokinetic agents. If gastric emptying is already showing delayed results or abnormal myoelectrical activity, Aetna considers antroduodenal manometry to have no additional diagnostic value — and won't cover it.

Anorectal manometry (CPT 91122 and 91125) and the rectal sensation, tone, and compliance test (CPT 91120 and 91124) are covered for two populations. First, members with chronic constipation (ICD-10 K59.0–K59.9) who have not responded to laxatives. Second, members with functional or structural fecal incontinence who have failed at least three months of conservative measures — supportive care, medical therapy, and pelvic floor physical therapy — and who have had a negative endoscopic evaluation (flexible sigmoidoscopy and/or colonoscopy). Both conditions require documented treatment failure before Aetna will treat this as medically necessary.

Colonic manometry (CPT 91117) is the most restricted of the group. Aetna covers it only to guide surgical decision-making in children with refractory colonic motility or defecatory disorders. Adult patients are not covered under this policy for colonic motility studies. If you're billing 91117 for adult patients, expect denial.

High-resolution esophageal manometry (CPT 91010, add-on +91013) is covered for diagnosing esophageal motility disorders in patients with dysphagia (ICD-10 R13.10–R13.19), including symptoms of achalasia, rumination syndrome, and PPI-refractory chest pain. It's also covered for pre-surgical evaluation in patients undergoing anti-reflux surgery. This is one of the cleaner coverage criteria in the policy — dysphagia plus high-resolution esophageal manometry billing is well-supported when documentation reflects the qualifying diagnosis.

Prior authorization requirements are not explicitly detailed in CPB 0616, but given the specificity of the medical necessity criteria and the number of non-covered indications, your team should confirm prior auth requirements with Aetna directly before scheduling these procedures. Don't assume the clinical criteria in the policy map one-to-one to your prior auth submission requirements.

Aetna Gastrointestinal Manometry Exclusions and Non-Covered Indications

This is where CPB 0616 gets costly if your billing team isn't paying attention. Aetna explicitly labels eight indications as experimental, investigational, or unproven. Claims submitted under these indications will be denied, and appeals will be difficult without new clinical evidence.

Antroduodenal manometry for any indication outside the covered criteria is not covered. Specifically, if gastric function testing already shows delayed emptying or abnormal myoelectrical activity, Aetna won't pay for antroduodenal manometry on top of that. The policy says it adds no proven diagnostic value in that scenario.

Colonic motility studies (CPT 91117) for any indication other than pediatric surgical guidance are experimental. Adult patients don't qualify under any circumstances in this policy.

High-resolution esophageal manometry for diaphragmatic flutter disease (ICD-10 J98.6) is explicitly non-covered. So is high-resolution manometry for chronic cough (ICD-10 R05.3). If a physician orders esophageal manometry for either of these and your team bills it, document carefully — but expect a fight.

Pharyngeal high-resolution manometry — with or without impedance — is not covered for evaluating swallowing or voice disorders in head and neck cancer patients (ICD-10 R49.0–R49.9), or for dysphagia evaluation (ICD-10 R13.10–R13.19). This is a meaningful distinction: regular high-resolution esophageal manometry for dysphagia is covered, but pharyngeal high-resolution manometry for dysphagia is not.

Upper esophageal sphincter manometry for esophageal motility disorders is also experimental.

MRI capsule marker methods for measuring whole gut transit in functional GI disorders — and for all other indications — are non-covered.

If your practice works with head and neck oncology referrals or chronic cough workups, flag this policy for your ordering physicians now. Submitting claims for these non-covered indications after February 27, 2026 without documented appeals strategy is a reimbursement risk your team should not take on.

Coverage Indications at a Glance

Aetna Gastrointestinal Manometry Billing Guidelines and Action Items 2026

Act on these before February 27, 2026. That's the effective date of CPB 0616 as modified, and claims submitted on or after that date will be evaluated under these updated criteria.

CPT, HCPCS, and ICD-10 Codes for Gastrointestinal Manometry Under CPB 0616

Covered CPT Codes (When Selection Criteria Are Met)

Key ICD-10-CM Diagnosis Codes