Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD (gastroesophageal reflux disease).
Treatment:  LINX Procedure, Pre-service.
The insurer denied the  LINX Procedure, Pre-service.
The denial is overturned.

This patient is a female with BMI (body mass index) of 32.74 and several year history of symptomatic GERD (gastroesophageal reflux disease) despite medication intake with PPI (proton pump inhibitor). UGI (upper gastrointestinal series) revealed a small hiatal hernia. Esophageal manometry was normal. EGD (esophagogastroduodenoscopy) revealed small hiatal hernia and esophagitis. 24 hour pH study revealed an elevated DeMeester score off 22.3 consistent with GERD (gastroesophageal reflux disease).

The LINX procedure was requested, which is the subject of this review.

Yes, the health plan should cover the LINX procedure.
This patient has GERD (gastroesophageal reflux disease) refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD (gastroesophageal reflux disease) in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. The exclusions to LINX and Nissen fundoplication include BMI (body mass index) > [greater than] 35, hiatal hernia > [greater than] 3 cm (centimeters), Barrett's esophagus with dysplasia, age < [less than] 18 and prior gastric or bariatric surgery. This patient does not document any exclusion to treatment with LINX, which is medically appropriate treatment for GERD (gastroesophageal reflux disease) for this patient.

Yes, the LINX procedure is more beneficial.
The patient has failed medical management and requests a standard surgical treatment for GERD (gastroesophageal reflux disease).

This patient has GERD (gastroesophageal reflux disease) refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD (gastroesophageal reflux disease) in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. The exclusions to LINX and Nissen fundoplication include BMI (body mass index) > [greater than] 35, hiatal hernia > [greater than] 3 cm (centimeters), Barrett's esophagus with dysplasia, age < [less than] 18 and prior gastric or bariatric surgery. This patient does not document any exclusion to treatment with LINX, which is medically appropriate treatment for GERD (gastroesophageal reflux disease) for this patient.