LCD/NCD Portal
Automated World Health
NCD100.4 ESOPHAGEAL MANOMETRY
Effective Date of this Version
10/2/1978
Benefit Category
• Diagnostic Tests (other).
• Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.
Item/Service Description
• The major use of esophageal manometry is to measure pressure within the esophagus to assist in the diagnosis of esophageal pathology including
o Aperistalsis.
o Spasm.
o Achalasia.
o Esophagitis.
o Esophageal ulcer.
o Esophageal congenital webs.
o Diverticuli.
o Scleroderma.
o Hiatus hernia.
o Congenital cysts.
o Benign and malignant tumors.
o Hypermobility.
o Hypomobility.
o Extrinsic lesions.
• Esophageal manometry is mostly used
o In difficult diagnostic cases.
o As an adjunct to X- rays and direct visualization of the esophagus (endoscopy) through the fiberscope.
Indications and Limitations of Coverage
• Esophageal manometry is covered under Medicare where it is determined to be reasonable and necessary for the individual patient.
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