TL;DR: The Centers for Medicare & Medicaid Services modified NCD 191, its National Coverage Determination for esophageal manometry, effective March 7, 2026. Here's what changes for billing teams.
CMS updated NCD 191 — the policy governing Medicare coverage of esophageal manometry — with a March 7, 2026 effective date. The policy does not list specific CPT or HCPCS codes, which creates real documentation and claims-processing headaches your billing team needs to get ahead of now. The coverage standard remains "reasonable and necessary for the individual patient," but the modification signals that CMS reviewed and affirmed this policy's framework, making it the current governing standard for any esophageal manometry claims billed to Medicare.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Esophageal Manometry |
| Policy Code | NCD 191 |
| Change Type | Modified |
| Effective Date | March 7, 2026 |
| Impact Level | Medium |
| Specialties Affected | Gastroenterology, General Surgery, Internal Medicine, Thoracic Surgery |
| Key Action | Audit your esophageal manometry claims for medical necessity documentation before March 7, 2026 — this policy's "reasonable and necessary" standard will be the governing framework for any denials after that date |
CMS Esophageal Manometry Coverage Criteria and Medical Necessity Requirements 2026
NCD 191 is the National Coverage Determination governing whether Medicare covers esophageal manometry. The core standard is "reasonable and necessary for the individual patient" — which sounds simple until you get a claim denial and realize CMS expects the medical record to actually demonstrate that.
The policy is clear about what esophageal manometry is for: measuring intraluminal esophageal pressure to assist in diagnosing esophageal pathology. CMS recognizes a broad set of covered diagnoses, including aperistalsis, esophageal spasm, achalasia, esophagitis, esophageal ulcer, esophageal congenital webs, diverticuli, scleroderma, hiatus hernia, congenital cysts, and benign and malignant esophageal tumors. Hypermobility, hypomobility, and extrinsic lesions are also included.
The policy specifically positions esophageal manometry as a tool for difficult diagnostic cases and as an adjunct to imaging — specifically X-rays and direct visualization via fiberoptic endoscopy. That language matters for your prior authorization and medical necessity documentation. If a patient hasn't had imaging or endoscopy first, you're going to have a harder time justifying the claim. CMS isn't saying those workups are required, but the policy's framing practically invites a medical necessity challenge if manometry is the first-line test.
NCD 191 does not reference prior authorization requirements directly. However, "reasonable and necessary" determinations at the MAC (Medicare Administrative Contractor) level often function like prior auth in practice — if the documentation doesn't support medical necessity, the claim gets denied on post-payment review. That's a slower, more expensive version of a prior auth denial.
The policy does not list specific CPT or HCPCS codes. That's not unusual for an older NCD, but it means you need to confirm with your MAC that the codes your team currently uses for esophageal manometry billing are aligned with how CMS processes claims under NCD 191. If there's any ambiguity, confirm before March 7, 2026.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Aperistalsis | Covered | Not specified in policy | Must be reasonable and necessary for the individual patient |
| Esophageal spasm | Covered | Not specified in policy | Typically adjunct to imaging or endoscopy workup |
| Achalasia | Covered | Not specified in policy | Must be reasonable and necessary for the individual patient |
| Esophagitis | Covered | Not specified in policy | Must be reasonable and necessary for the individual patient |
| Esophageal ulcer | Covered | Not specified in policy | Must be reasonable and necessary for the individual patient |
| Esophageal congenital webs | Covered | Not specified in policy | Must be reasonable and necessary for the individual patient |
| Diverticuli | Covered | Not specified in policy | Must be reasonable and necessary for the individual patient |
| Scleroderma | Covered | Not specified in policy | Must be reasonable and necessary for the individual patient |
| Hiatus hernia | Covered | Not specified in policy | Must be reasonable and necessary for the individual patient |
| Congenital cysts | Covered | Not specified in policy | Must be reasonable and necessary for the individual patient |
| Benign esophageal tumors | Covered | Not specified in policy | Must be reasonable and necessary for the individual patient |
| Malignant esophageal tumors | Covered | Not specified in policy | Must be reasonable and necessary for the individual patient |
| Hypermobility | Covered | Not specified in policy | Must be reasonable and necessary for the individual patient |
| Hypomobility | Covered | Not specified in policy | Must be reasonable and necessary for the individual patient |
| Extrinsic lesions | Covered | Not specified in policy | Must be reasonable and necessary for the individual patient |
CMS Esophageal Manometry Billing Guidelines and Action Items 2026
The modification to NCD 191 is a signal to review your current process — not a fire drill, but not something to defer until April either. Here's what to do before March 7, 2026.
| # | Action Item |
|---|---|
| 1 | Confirm which CPT codes your team currently uses for esophageal manometry and verify they're processing correctly under NCD 191. The policy does not list specific codes. Contact your MAC directly or check your MAC's Local Coverage Determinations (LCDs) for any code-level guidance that layers on top of this NCD. MAC-level policy often carries the coding specifics that NCDs omit. |
| 2 | Audit your medical necessity documentation templates for esophageal manometry. The "reasonable and necessary" standard in NCD 191 needs to show up in your clinical notes. The physician's documentation should connect the patient's presentation to one of the covered indications listed in the policy — aperistalsis, achalasia, scleroderma, etc. Generic "esophageal evaluation" language won't hold up on review. |
| 3 | Flag cases where esophageal manometry was ordered without prior imaging or endoscopy. The policy explicitly frames manometry as an adjunct to X-rays and endoscopy in difficult diagnostic cases. If your documentation doesn't explain why imaging or endoscopy was insufficient or contraindicated, that's a claim denial waiting to happen. Add a documentation prompt for ordering physicians to address this. |
| 4 | Review your denial patterns for esophageal manometry claims in the last 12 months. If you've been seeing denials citing medical necessity, the modified NCD 191 is a good moment to retrain your team on what CMS requires. A pattern of denials before March 7, 2026 is evidence you need process changes, not just policy awareness. |
| 5 | If your practice performs high-volume esophageal manometry — particularly in GI or thoracic surgery — loop in your compliance officer before March 7, 2026. "Modified" NCDs sometimes accompany MAC-level LCD updates that affect reimbursement rates or coverage criteria at the local level. Make sure there's no downstream LCD change at your MAC that this NCD modification is paired with. |
| 6 | Check your charge capture workflow to ensure the correct diagnosis codes are attached to esophageal manometry claims. Since NCD 191 lists specific covered indications, your billing team needs to confirm that ICD-10-CM codes submitted with the claim correspond to those indications. A manometry claim with a vague or unrelated diagnosis code is an easy target for a medical necessity denial. |
| 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 Esophageal Manometry Under NCD 191
NCD 191 does not list specific CPT, HCPCS, or ICD-10 codes. This is the most practically frustrating aspect of this policy for billing teams.
This doesn't mean billing esophageal manometry to Medicare is a free-for-all. It means the code-level guidance lives at the MAC level, not in the NCD itself. Your MAC's LCD — if one exists for esophageal manometry in your jurisdiction — is the document that will list covered CPT codes, covered diagnoses, and documentation requirements.
Check with your MAC directly. If you're not sure which MAC covers your jurisdiction, CMS maintains a current MAC jurisdiction map at cms.gov. The absence of codes in NCD 191 is a documentation and verification problem, not a coverage problem — but it becomes a reimbursement problem if your team assumes everything is fine without confirming.
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