Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 11202 | Palmetto GBA | A and B and HHH MAC | SC |
| 11302 | Palmetto GBA | A and B and HHH MAC | VA |
| 11402 | Palmetto GBA | A and B and HHH MAC | WV |
| 11502 | Palmetto GBA | A and B and HHH MAC | NC |
| 10112 | Palmetto GBA | A and B MAC | AL |
| 10212 | Palmetto GBA | A and B MAC | GA |
| 10312 | Palmetto GBA | A and B MAC | TN |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A56724 (Billing and Coding: Wireless Gastrointestinal Motility Monitoring Systems) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A56724: Billing and Coding: Wireless Gastrointestinal Motility Monitoring Systems (Billing and Coding, effective 2019-10-17)
- Covered ICD-10-CM codes
- 10
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 1
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| K31.84 | — |
| K31.9 | — |
| K58.1 | — |
| K58.2 | — |
| K58.8 | — |
| K59.01 | — |
| K59.03 | — |
| K59.04 | — |
| K59.2 | — |
| R11.10 | — |
Procedure codes: 91112.
Coverage indications, limitations and medical necessity
A Wireless Gastrointestinal Motility Monitoring System is an ingestible capsule with the trade name SmartPill ® . The SmartPill ® records data enabling the estimation of regional and total gastrointestinal motility. The device is Food and Drug Administration (FDA) approved to evaluate patients with suspected delayed gastric emptying and the evaluation of colonic transit time in patients with chronic idiopathic constipation. The capsule device measures pH, temperature, and pressure while traveling through the gastrointestinal (GI) tract, sending the data to a wireless receiver worn on or near the patient. The data can be used to determine GI motility, gastric emptying, small bowel transit, colonic transit, and whole gut transit times. The capsule can also provide pressure patterns within the GI tract. The study can be done in a physician office after the patient has discontinued use of all medications that affect the GI tract.
Indications
The Wireless Motility Capsule (WMC) has been studied in many centers. The capsule does not use radioactive materials and has minimal safety risks. Palmetto GBA will cover the device when:
• It is used by a gastroenterologist trained to use and interpret the results.
• It is used to evaluate and/or treat patients with suspected gastroparesis of any nature.
• It is used to evaluate colonic transit in patients with chronic idiopathic constipation lasting over 6 months.
• Basic clinical investigations, including endoscopy, have failed to elucidate a diagnosis.
Limitations
The WMC should not be administered to patients with a history of gastric bezoar, swallowing disorders, dysphagia, suspected strictures/fistulae in the GI tract, physiologic GI obstruction, GI surgery within the previous 3 months, Crohn’s disease, diverticulitis, or who have an implanted electromechanical medical device (such as pacemaker or infusion pump). The capsule is not FDA approved for use in children.
Summary of evidence (opening)
N/A
The contractor cites 5 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2021-09-09
- Last reviewed by the contractor
- 2021-08-03
- MCD version
- 31
- Derived from
- L32853
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Palmetto GBA hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L33455 cover?
A Wireless Gastrointestinal Motility Monitoring System is an ingestible capsule with the trade name SmartPill ® . The SmartPill ® records data enabling the estimation of regional and total gastrointestinal motility. The device is Food and Drug Administration (FDA) approved to evaluate patients with suspected delayed gastric emptying and the evaluation of colonic transit time in patients with chronic idiopathic… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L33455 apply to?
Palmetto GBA applies it to Medicare claims in AL, GA, NC, SC, TN, VA, WV. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L33455?
The companion billing and coding article A56724 lists 10 ICD-10-CM codes in 1 group that support medical necessity; the first 10 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L33455?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.