Description:
An ingestible pH and pressure-sensing capsule (SmartPill GI Monitoring System) measures pH, pressure, and temperature changes to signify passage of the capsule through portions of the gastrointestinal tract. It is proposed as a means of evaluating gastric emptying for diagnosis of gastroparesis, and colonic transit times for the diagnosis of slow-transit constipation.

For individuals who have suspected disorders of gastric emptying or suspected slow-transit constipation who receive ingestible pH and pressure capsule, the evidence includes studies of test characteristics and case series of patients who have undergone the test. Relevant outcomes are test accuracy and validity, other performance measures, symptoms, functional outcomes, and health status measures. The available studies have provided some comparative data on the comparison of the SmartPill ingestible pH plus pressure-sensing capsule and other techniques for measuring gastric emptying and colonic transit times. This evidence primarily consists of concordance with available tests. Because the available tests (e.g., gastric emptying scintigraphy) are imperfect criterion standards, it is not possible to determine the true sensitivity and specificity of SmartPill. The results of the concordance studies have revealed a moderate correlation with alternative tests, but have provided only limited further data on the true accuracy of the test in clinical care. Evaluation of cases with discordant results would be of particular value and, ideally, these studies should be linked to therapeutic decisions and to meaningful clinical outcomes.

Background 
Gastroparesis is a chronic disorder characterized by delayed gastric emptying in the absence of mechanical obstruction. Symptoms of gastroparesis are often nonspecific and may mimic other gastrointestinal tract disorders. It can be caused by many conditions; most commonly it is idiopathic, diabetic, or postsurgical.

Constipation is a chronic disorder involving infrequent bowel movements, a sensation of obstruction, and incomplete evacuation. Many medical conditions can cause constipation, such as mechanical obstruction, metabolic conditions, myopathies, and neuropathies. Diagnostic testing for constipation can aid in distinguishing between 2 categories of disorders, slow-transit constipation and pelvic floor dysfunction.

Gastric emptying scintigraphy is considered the reference standard for diagnosing gastroparesis. The patient ingests a radionuclide-labeled standard meal and subsequent imaging is performed at 0, 1, 2, and 4 hours postprandially, to measure how much of the meal has passed beyond the stomach. A typical threshold to indicate abnormal gastric emptying is more than 10% of the meal remaining at 4 hours after ingestion.

Standard tests used in the evaluation of constipation include ingestion of radiopaque markers and colonic transit scintigraphy. In the radiopaque markers test, small markers are ingested over 1 or several days, and abdominal radiographs are performed at 4 and/or 7 days. The number of remaining markers correlates with the colonic transit time. In colonic transit scintigraphy, a radio-labeled meal is ingested, followed by scintigraphic imaging at several time intervals. The location of the scintigraphic signals correlates with colonic transit times.

Regulatory Status
In 2006, an ingestible capsule (SmartPill® GI Monitoring System; Given Imaging) was cleared for marketing by the U.S. Food and Drug Administration through the 510(k) process, for evaluation of delayed gastric emptying. Gastric emptying is signaled when the pH monitor in the capsule indicates a change in pH from the acidic environment of the stomach to the alkaline environment of the small intestine. For example, an increase of 2 or more pH units usually indicates gastric emptying, and a subsequent decrease of 1 or more pH units usually indicates a passage to the ileocecal junction. While SmartPill^® does not measure 50% emptying time, it can be correlated with scintigraphically measured 50% emptying time. The capsule also measures pressure and temperature during its transit through the entire gastrointestinal tract, allowing calculations of total gastrointestinal tract transit time. In 2009, the Food and Drug Administration expanded the use of the SmartPill^® to determine colonic transit time for the evaluation of chronic constipation and to differentiate between slow- and normal- transit constipation. When colonic transit time cannot be determined, small and large bowel transit times combined can be used instead. The SmartPill^® is not for use in pediatric patients.

Related Policies
20120 Esophageal pH Monitoring
60133 Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon

Policy: 
Measurement of gastrointestinal transit times, including gastric emptying and colonic transit times, using an ingestible pH and pressure capsule is considered MEDICALLY NECESSARY for the evaluation of suspected gastroparesis, constipation, or other gastrointestinal motility disorders as an alternative to other techniques to evaluate these conditions.

Policy Guidelines
There is a CPT category I code specific to this procedure:

91112: Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report.

Benefit Application
BlueCard/National Account Issues
State or federal mandates (e.g., FEP) may dictate that all FDA-approved devices, drugs, or biologics may not be considered investigational, and thus these devices may be assessed only on the basis of their medical necessity.

Rationale
Evidence reviews assess whether a medical test is clinically useful. A useful test provides information to make a clinical management decision that improves the net health outcome. That is, the balance of benefits and harms is better when the test is used to manage the condition than when another test or no test is used to manage the condition.

The first step in assessing a medical test is to formulate the clinical context and purpose of the test. The test must be technically reliable, clinically valid, and clinically useful for that purpose. Evidence reviews assess the evidence on whether a test is clinically valid and clinically useful. Technical reliability is outside the scope of these reviews, and credible information on technical reliability is available from other sources.

Wireless pH and Pressure Capsules
Clinical Context and Test Purpose
The purpose of diagnostic testing with an ingestible pH and pressure capsule in patients who have suspected disorders of gastric emptying or have suspected slow-transit constipation is to inform a decision whether to proceed to appropriate treatment.

The question addressed in this evidence review is: Does diagnostic testing with an ingestible pH and pressure capsule improve the net health outcome in individuals with suspected disorders of gastric emptying or with suspected slow-transit constipation?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with suspected disorders of gastric emptying or with suspected slow-transit constipation.

Interventions
The test being considered is diagnostic testing with an ingestible pH and pressure capsule.

Comparators
The following tests are currently being used to diagnose suspected disorders of gastric emptying or slow-transit constipation: scintigraphy and radiopaque markers.

Although scintigraphy is considered the reference standard for evaluating gastric emptying, several issues complicate its use as a reference test. Until recently, there has been a lack of test standardization.¹ Significant day-to-day variability in the rate of gastric emptying has also been noted.² Due to a lack of standardization and small sample sizes referenced in published studies, the capability of the gastric emptying test to discriminate between healthy individuals and those with known gastroparesis is uncertain. In a study by Tougas et al. (2000), 123 healthy subjects were assessed to determine the normal period required for nearly complete evacuation of a standardized meal from the stomach.³ The authors suggested that the threshold of normality for gastric retention at 4 hours is 10% meal retention. The cutoff point was set to include 95% of normal persons. However, it appears to be unknown if this same threshold adequately identifies persons who would otherwise be classified as having gastroparesis and who are candidates or responders to treatment.

Outcomes
The general outcomes of interest are reductions in gastrointestinal discomfort and pain and improvements in quality of life. Comparisons between the ingestible capsule and scintigraphy could be done concurrently.

Technically Reliable
Assessment of technical reliability focuses on specific tests and operators and requires review of unpublished and often proprietary information. Review of specific tests, operators, and unpublished data are outside the scope of this evidence review and alternative sources exist. This evidence review focuses on the clinical validity and clinical utility.

Clinically Valid
A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).

Gastric Emptying
Systematic Reviews
A few published studies have evaluated the ingestible capsule in relation to another diagnostic measure of gastric emptying. A systematic review of 12 studies on the Evidence reviews assess whether a medical test is clinically useful. A useful test provides information to make a clinical management decision that improves the net health outcome. That is, the balance of benefits and harms is better when the test is used to manage the condition than when another test or no test is used to manage the condition.

The first step in assessing a medical test is to formulate the clinical context and purpose of the test. The test must be technically reliable, clinically valid, and clinically useful for that purpose. Evidence reviews assess the evidence on whether a test is clinically valid and clinically useful. Technical reliability is outside the scope of these reviews, and credible information on technical reliability is available from other sources.

Wireless pH and Pressure Capsules
Clinical Context and Test Purpose
The purpose of diagnostic testing with an ingestible pH and pressure capsule in patients who have suspected disorders of gastric emptying or have suspected slow-transit constipation is to inform a decision whether to proceed to appropriate treatment.

The question addressed in this evidence review is: Does diagnostic testing with an ingestible pH and pressure capsule improve the net health outcome in individuals with suspected disorders of gastric emptying or with suspected slow-transit constipation?

The following PICO was used to select literature to inform this review.

Populations
The relevant population of interest is individuals with suspected disorders of gastric emptying or with suspected slow-transit constipation.

Interventions
The test being considered is diagnostic testing with an ingestible pH and pressure capsule ingestible capsule was conducted by Stein et al. (2013) for the Agency for Healthcare Research and Quality (AHRQ; see Table 1).⁴ Studies that included only healthy participants were excluded from the review; instead, AHRQ looked for studies with comparison groups consisting of healthy, asymptomatic (i.e., without symptoms of gastroparesis or constipation) participants as controls. Among these studies, five were only available as meeting presentations, and the overall strength of evidence favoring the ingestible capsule was low. Diagnostic accuracy with the ingestible capsule was considered comparable to gastric scintigraphy in 7 studies, 3 of which were in abstracts only. There was a moderate correlation between the ingestible capsule and gastric emptying scintigraphy on transit data and device agreement in 5 studies.

Table 1. Characteristics and Results of Systematic Reviews

AHRQ: Agency for Healthcare Research and Quality; Sens: sensitivity; SOE: strength of evidence; Spec: specificity.

Diagnostic Studies
A study by Green et al. (2013) assessed SmartPill and gastric emptying scintigraphy in 22 pediatric patients with severe upper gastrointestinal (GI) symptoms.⁵ Of 20 evaluable patients who had both tests, 9 patients had delayed gastric emptying identified by scintigraphy. SmartPill was 100% sensitive and 50% specific for delayed gastric emptying. Patients also underwent antroduodenal manometry to detect motor abnormalities. SmartPill identified motor abnormalities in 17 patients compared with 10 detected by antroduodenal manometry. However, because there does not appear to be a reference standard for motor abnormalities, it cannot be determined whether SmartPill is more sensitive or whether it has a higher false-positive rate for detection of motor abnormalities.

Section Summary: Clinical Validity for Gastric Emptying
The data present several shortcomings on the use of the SmartPill in diagnosing gastroparesis; as a result, the diagnostic accuracy is not well defined. The current reference test (gastric emptying scintigraphy) is an imperfect criterion standard, and this creates difficulties in defining the sensitivity and specificity of SmartPill. Studies included healthy asymptomatic subjects as part of a control group. Although there was a moderate correlation between SmartPill gastric emptying time and scintigraphy, scintigraphy itself has limited reliability. Although the areas under the curve between SmartPill and scintigraphy are similar, the modest correlation between the two tests indicates that there are often discordant results.

Constipation
Few studies have evaluated the use of SmartPill for assessing colonic transit times. In the systematic review by Stein et al. (2013) conducted for AHRQ, the strength of evidence in available studies on the ingestible capsule was found to be low overall.⁴ No studies were identified that compared the SmartPill to colonic scintigraphy. Accuracy of the ingestible capsule in diagnosing slow-transit constipation was similar to tests using radiopaque markers. A moderate correlation between colonic transit times with the ingestible capsule and tests with radiopaque markers was shown in 5 studies (r range, 0.69 – 0.71).

Section Summary: Clinical Validity for Constipation
Although the studies included in the AHRQ systematic review showed moderate correlations between SmartPill and other methods for assessing colonic transit times, they should be interpreted cautiously. The diagnostic capability of SmartPill for detecting slow-transit constipation is unknown.

Clinically Useful
A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if patients receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.

Direct Evidence
Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be from randomized controlled trials. No randomized controlled trials were identified.

Gastric Emptying and Constipation
The 2013 AHRQ review found that there was a lack of evidence on the clinical utility of testing with the ingestible capsule.⁴ The review found 3 studies, including 1 abstract, on management changes following use of the SmartPill. Kuo et al. (2011)⁶ and Rao et al. (2011)⁷ reported that wireless motility capsule testing resulted in a new diagnosis in about 50% of patients. Due to the limited data, AHRQ reviewers considered the evidence insufficient to determine the impact of testing results of the ingestible capsule on treatment and management decisions.

Chain of Evidence
Indirect evidence on clinical utility rests on clinical validity. If the evidence is insufficient to demonstrate test performance, no inferences can be made about clinical utility.

Because the clinical validity of an ingestible pH and pressure capsule has not been established, a chain of evidence supporting the clinical utility of the device cannot be constructed.

Section Summary: Clinically Useful
Evidence on the clinical utility of a wireless pressure capsule is very limited, consisting of 3 retrospective analyses describing outcomes of patients undergoing testing with SmartPill. These studies lacked control subjects diagnosed without the test or with alternative tests. This evidence is insufficient to determine the clinical utility of SmartPill for either indication; higher quality studies are still needed to measure the impact of SmartPill on patient management and improved health outcomes.

Summary of Evidence
For individuals who have suspected disorders of gastric emptying or suspected slow-transit constipation who receive diagnostic testing with an ingestible pH and pressure capsule, the evidence includes studies of test characteristics and case series of patients who have undergone the test. Relevant outcomes are test validity, other performance measures, symptoms, functional outcomes, and health status measures. The available studies have provided some comparative data on the SmartPill ingestible pH plus pressure-sensing capsule and other techniques for measuring gastric emptying. This evidence primarily consists of assessments of concordance with available tests. Because the available tests (e.g., gastric emptying scintigraphy) are imperfect criterion standards, it is not possible to determine the true sensitivity and specificity of SmartPill. The results of the concordance studies have revealed a moderate correlation with alternative tests, but have provided only limited additional data on the true accuracy of the test in clinical care. Evaluation of cases with discordant results would be of particular value and, ideally, these studies should be linked to therapeutic decisions and to meaningful clinical outcomes. The evidence to date on the clinical utility of testing is lacking, consisting of a small number of retrospective studies. It is not possible to determine whether there is net improvement in health outcomes using SmartPill vs standard diagnostic tests. The evidence is insufficient to determine the effects of the technology on health outcomes.

Practice Guidelines and Position Statements
American and European Neurogastroenterology and Motility Societies
In 2011, the American and European Neurogastroenterology and Motility Societies issued a position paper on the evaluation gastrointestinal transit.⁸ In it, the wireless motility capsule was recommended by consensus for assessing gastric emptying and small bowel, colonic, and whole-gut transit times in patients with suspected gastroparesis or gastrointestinal dysmotility in multiple regions. However, the position paper noted that the clinical utility of identifying delays in small bowel transit times is unknown. 

American Gastroenterological Association
In 2013, the American Gastroenterological Association’s guidelines on gastroparesis diagnosis and treatment indicated wireless motility capsule testing requires validation before it can be considered as an alternative to scintigraphy for diagnosing gastroparesis.⁹ Gastric emptying scintigraphy was considered the best-accepted method to test for delays in gastric emptying.

U.S. Preventive Services Task Force Recommendations
Not applicable

Ongoing and Unpublished Clinical Trials
A search of ClinicalTrials.gov in August 2020 did not identify any ongoing or unpublished trials that would likely influence this review.

References:  

1. Abell TL, Camilleri M, Donohoe K, et al. Consensus recommendations for gastric emptying scintigraphy: a joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. J Nucl Med Technol. Mar 2008; 36(1): 44-54. PMID 18287197
2. Parkman HP, Hasler WL, Fisher RS. American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology. Nov 2004; 127(5): 1592-622. PMID 15521026
3. Tougas G, Eaker EY, Abell TL, et al. Assessment of gastric emptying using a low fat meal: establishment of international control values. Am J Gastroenterol. Jun 2000; 95(6): 1456-62. PMID 10894578
4. Stein E, Berger Z, Hutfless S, et al. Wireless Motility Capsule Versus Other Diagnostic Technologies for Evaluating Gastroparesis and Constipation: A Comparative Effectiveness Review. Rockville, MD: Agency for Healthcare Research and Quality; 2013.
5. Green AD, Belkind-Gerson J, Surjanhata BC, et al. Wireless motility capsule test in children with upper gastrointestinal symptoms. J Pediatr. Jun 2013; 162(6): 1181-7. PMID 23290514
6. Kuo B, Maneerattanaporn M, Lee AA, et al. Generalized transit delay on wireless motility capsule testing in patients with clinical suspicion of gastroparesis, small intestinal dysmotility, or slow transit constipation. Dig Dis Sci. Oct 2011; 56(10): 2928-38. PMID 21625964
7. Rao SS, Mysore K, Attaluri A, et al. Diagnostic utility of wireless motility capsule in gastrointestinal dysmotility. J Clin Gastroenterol. Sep 2011; 45(8): 684-90. PMID 21135705
8. Rao SS, Camilleri M, Hasler WL, et al. Evaluation of gastrointestinal transit in clinical practice: position paper of the American and European Neurogastroenterology and Motility Societies. Neurogastroenterol Motil. Jan 2011; 23(1): 8-23. PMID 21138500
9. Camilleri M, Parkman HP, Shafi MA, et al. Clinical guideline: management of gastroparesis. Am J Gastroenterol. Jan 2013; 108(1): 18-37; quiz 38. PMID 23147521

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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