Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Disease (GERD)
Treatment: proposed service code 43210 (esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed)
The insurer denied coverage for proposed service code 43210 (esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed).
The denial is upheld.

This is an adult with a history of gastroesophageal reflux disease (GERD). The patient had an upper gastrointestinal (GI) endoscopy. The report stated gastroesophageal flap valve classified as Hill Grade II (fold present, opens with respiration). Based on the work up, the physician recommended the patient proceed with Transoral Incisionless Fundoplication (TIF).

TIF offers an endoscopic approach to the treatment of gastroesophageal reflux disease (GERD) [1]. TIF received original Food and Drug Administration (FDA) approval [8]. Studies have demonstrated that TIF has led to improved quality of life and improvements in GERD symptoms with short-term follow-up. Long-term studies regarding the impact of TIF are lacking [1]. TIF for chronic GERD is a safe, minimally invasive alternative to surgery in selected patients [2]. Nissen fundoplication is the gold standard procedure for treatment of GERD. Nissen fundoplication, TIF, and magnetic sphincter augmentation (MSA) have been shown to have comparable effectiveness [3]. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) states that TIF leads to better control of GERD symptoms compared with proton pump inhibitor (PPI) treatment, and that least invasive endoscopic procedures should be attempted before more complex, surgical procedures [4]. Patients who have undergone TIF have elimination of troublesome GERD symptoms, including regurgitation. The procedure is a cost-effective alternative to laparoscopic Nissen fundoplication [5]. TIF is associated with persistent GERD in some patients. Laparoscopic Nissen fundoplication has been the standard treatment for GERD management in patients who have had other previous antireflux procedures [6, 7].

Per clinical documentation, this is a patient with a history of GERD. Current medications for GERD include Protonix and Zantac. The patient presented with heartburn. The patient had an upper endoscopy that demonstrated a Hill grade II gastroesophageal flap valve and gastric polyps. There is no description of the patient's current symptoms. There is no indication through manometry, endoscopy, or pH testing that the patient has recurrent GERD. Due to lack of symptoms, consistent with GERD, and no clinical evidence of recurrent GERD, the patient is not a good candidate for TIF. TIF would not be the best available treatment for this patient at this time.

In summary, the denial of proposed service code 43210 (esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk may be increased over standard treatments.