Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hiatal Hernia, Gastroesophageal Reflux Disease (GERD).
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial was upheld.

This is a female patient with a history of hiatal hernia and gastroesophageal reflux disease (GERD).  The patient is followed by bariatric surgery; her Body Mass Index (BMI) is 33.  The patient presented to his office for follow up for a gallbladder workup.  The patient reported that she sleeps with a bucket at her bedside with her head elevated due to the persistent feelings of a lump in the throat, mucous and cough.  She had consulted Gastroenterology.  A esophagogastroduodenoscopy (EGD) was done, which revealed a hiatal hernia with free gastroesophageal reflux (GER).  Pantoprazole was increased, and she has been treated with Zofran and Regan.  An abdominal ultrasound was performed that showed hepatomegaly and hepatic steatosis.  A hepatobiliary scan with cholecystokinin (CCK) was performed that revealed a suboptimal ejection fraction of 18%.  The diagnosis was hiatal hernia with GERD and biliary dyskinesia.  Recommendations were made for manometry and pH probe testing.  It was reported that the patient has severe reflux with a workup including a pH probe showing a significantly elevated DeMeester score.  Manometry showed some spasticity, but normal distal contractile integral (DCI) and 100% clearance with no esophagogastric junction (EGJ) outflow obstruction.  Fluoroscopy showed a small hiatal hernia and an upper endoscopy showed a 4 to 5 cm hiatal hernia with significant esophagitis.  Surgical options were discussed with the patient with a plan towards a hiatal hernia repair with the LINX system.  The patient underwent ambulatory pH probe monitoring on 12/10/19 which revealed Demeester score positive of 67.1 and symptom association probability of 100%.  

Based on the information provided, these criteria are not met because the patient did not have any of these conditions.  Additionally, as per criteria from the guideline "implantable magnetic esophageal ring (LINX)"- the role of this treatment remains uncertain.  There is not enough evidence proving that it is useful or that it improves health outcomes over standard treatments for the condition.  The medical necessity for a hospital admission has not been established.  The request is denied. 

The health care plan did act reasonably and with sound medical judgment and in the patient's best interest as there was not enough evidence to support the LINX procedure in improving health outcomes in this patient.  They were also correct in denying the inpatient admission, as this procedure, when it is done, could be done as an ambulatory procedure and if need be with 23-hour observation.  It does not require an inpatient stay. 

Therefore, based upon the records, the insurer is correct in denying the LINX, as the procedure is not indicated in this patient with a large hiatal hernia, stricture and Grade C esophagitis.  The inpatient admission was not considered medically necessary, as the LINX procedure was not indicated in this patient given her clinical history and findings.  

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.