Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD (gastroesophageal reflux disease). 
Treatment: LINX Procedure. 

The insurer denied: LINX Procedure. 
The denial is overturned. 

The patient is an adult male with long-standing reflux disease. He has been treated with medication, diet and lifestyle changes for his GERD (gastroesophageal reflux disease) with esophagitis. He has not achieved good control of his GERD (gastroesophageal reflux disease). His workup revealed a hiatal hernia and a very high Demeester score on his pH testing. Esophageal manometry was normal. The patient's symptoms include heartburn, cough and waking up with acid backwash. The LINX procedure was denied coverage by the health plan based on the determination that Esophagus Sphincter Augmentation is experimental and investigational. The denial was appealed based on the facts that the procedure is no longer considered experimental or investigational and has been accepted by multiple national surgical organizations, and Insurance companies and is FDA (United States Food and Drug Administration) approved for this indication. 

The health plan should cover the LINX procedure. 

Laparoscopic esophageal sphincter augmentation has been studied for over a decade. A multitude of studies have proven its effectiveness compared to both PPI (proton pump inhibitor) medical management and Fundoplication. Due to his history of Clostridium difficile enteritis, this patient is not a candidate for long-term, standard treatment with PPIs (proton pump inhibitors). Studies have shown that laparoscopic esophageal sphincter augmentation has significantly less gas bloat syndrome compared to Nissen Fundoplication. Also, patients preserve the ability to belch and vomit with esophageal sphincter augmentation unlike with fundoplication. Laparoscopic esophageal sphincter augmentation involves less alteration of anatomy and less disruption of the tissue. It is also much easier to reverse if needed. The procedure is FDA (United States Food and Drug Administration) approved and recognized by many insurance companies as medically appropriate and not experimental/investigational. When a surgical procedure becomes mainstream and a viable treatment option in the community, it is no longer considered experimental or investigational. 

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and American Society of General Surgeons (ASGS) have both endorsed esophageal sphincter augmentation as a surgical treatment option for GERD (gastroesophageal reflux disease). 

The requested LINX procedure is more beneficial. 

Studies have shown that laparoscopic esophageal sphincter augmentation has significantly less gas bloat syndrome compared to Nissen Fundoplication. Also, patients preserve the ability to belch and vomit with esophageal sphincter augmentation, unlike with fundoplication. Laparoscopic esophageal sphincter augmentation involves less alteration of anatomy and less disruption of the tissue. It is also much easier to reverse if needed. With this patient's young age, the LINX procedure has the advantage of fewer anatomical changes, less tissue disruption, and fewer postoperative long-term side effects as compared to a Nissen fundoplication.