Gastric Electrical Stimulation (GES)

Gastric Electrical Stimulation (GES) A. The Division of Medicaid covers Gastric Electrical Stimulation (GES) when used for the treatment of chronic intractable (drug-refractory) nausea and vomiting secondary to gastro- paresis of diabetic or idiopathic etiology. The Food and Drug Administration has approved the GES device through a humanitarian exemption. B. The beneficiary’s medical record must contain documentation that the implanting facility’s institutional review board (IRB) or equivalent governing body has approved the implantation of the GES for the specific indications listed in Rule 4.23 A. C. GES is considered medically necessary if a beneficiary has a diagnosis of gastroparesis and meets all of the following criteria: 1. Is refractory or intolerant of two (2) out of three (3) classes of prokinetic medications and two (2) out of three (3) antiemetic medications, 2. Has significantly delayed gastric emptying as documented by standard scintigraphic imaging of solid food, 3. Has a poor nutritional status and enteral feedings or total parental nutrition (TPN) is medically necessary, and 4. Is age eighteen (18) through seventy (70). D. All other indications including, but not limited to, the treatment of obesity, are considered investigational and not medically necessary. E. GES is not covered for beneficiaries who are: 1. Pregnant, 2. Suffering from chemical dependency, 3. Undergoing peritoneal dialysis, or 4. Terminal with a limited life expectancy based on a diagnosis of cancer. F. Prior authorization by the UM/QIO is required.