Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: GERD (gastroesophageal reflux disease).
Treatment: LINX Reflux Management System (43284) and Inpatient Stay.

The insurer denied the LINX Reflux Management System (43284) and Inpatient Stay. The denial is upheld. 

This patient is a male with long-standing (7+ years) GERD (gastroesophageal reflux disease) that refractory to medication. BMI (body mass index) is reported as 34.7 kg (kilograms)/m2 (meters squared) on EGD (esophagogastroduodenoscopy), however, based on height of 5 feet 6 inches and weight 215 pounds, the patient would actually have a BMI (body mass index) of 35.5 kg (kilograms)/m2 (meters squared). On PE (physical examination) , the patient had a height of 5 feet 5 inches and 220 pounds. Even if height of 5 feet 6 was used, the calculated BMI (body mass index) would be 35.5 kg (kilograms)/m2 (meters squared) and if 5 feet 5 inches were used, BMI (body mass index) would be 36.6 kg (kilograms)/m2 (meters squared).  EGD (esophagogastroduodenoscopy) revealed a hiatal hernia without evidence of Barrett's esophagus. UGI (upper gastrointestinal series) revealed hiatal hernia. Manometry was WNL (within normal limits). 24 hour pH (potential of hydrogen) evaluation revealed an elevated DeMeester score consistent with GERD (gastroesophageal reflux disease).  

No, the health plan should not cover the LINX Reflux Management System (43284) and Inpatient Stay.

Although LINX is a standard treatment for GERD (gastroesophageal reflux disease), this patient meets one of the manufacturer's contraindication criteria, which is BMI (body mass index) that is greater than 35 kg (kilograms)/m2 (meters squared), in which weight loss and/or possibly bariatric surgery has been documented to be a better treatment for GERD (gastroesophageal reflux disease) with higher failure rates for surgical anti-reflux procedures such as laparoscopic Nissen fundoplication. LINX has not been clinically studied in patients with morbid obesity or BMI (body mass index) greater than 35 kg (kilograms)/m2 (meters squared). There is some confusion as to the height of the patient, whether the patient is 5 feet 5 inches tall or 5 feet 6 inches tall, as two different heights are utilized in the medical records. However, regardless, both weights of 215 pounds  and/or 220 pounds would calculate using the NHLBI (National Heart, Lung, and Blood Institute) BMI (body mass index) calculator as greater than 35 kg (kilograms)/m2 (meters squared). Given that LINX is not medically indicated for this patient, inpatient admission is also not considered medically appropriate. 

No, the LINX Reflux Management System (43284) and Inpatient Stay is not likely to be more beneficial.

Although LINX is a standard surgical treatment for GERD (gastroesophageal reflux disease), there are several exclusions to treatment: age <21 years, BMI (body mass index) > 35 kg (kilograms)/m2 (meters squared), prior bariatric or gastric surgery, Barrett's esophagus with dysplasia, untested in hiatal hernia > 4 cm (centimeters). This patient has a BMI (body mass index) of > 35 kg (kilograms)/m2 (meters squared). LINX has not been clinically studied in patients with morbid obesity or BMI (body mass index) greater than 35 kg (kilograms)/m2 (meters squared). Therefore, LINX is not medically appropriate for this patient. Given that LINX is not indicated for this patient, inpatient stay is also not determined to be medically appropriate.