Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Gastroesophageal Reflux Disease (GERD). 
Treatment: Procedure code 43210 to treat heartburn (transoral incisionless fundoplication procedure using the EsophyX). 

The insurer denied coverage for procedure code 43210 to treat heartburn (transoral incisionless fundoplication procedure using the EsophyX). 

The denial is overturned. 

This case involves a patient who has a history of gastroesophageal reflux disease.  The documentation indicated she has experienced chronic symptoms such as regurgitation, belching, and heartburn despite the utilization of Dexilant 60 mg (milligram).  The documentation does include an esophagogastroduodenoscopy (EGD) which revealed benign neoplasm of stomach and other gastritis without bleeding.  She was seen for evaluation of extra esophageal manifestations of gastroesophageal reflux disease.  She complained of having a sore throat.  She did indicate this has been present for a few months.  She indicated this initially started after sinusitis which was refractory to 2 courses of antibiotics.  She did improve and her course was complicated with C. (clostridioides) difficile.  Since then, she has noticed an increase in reflux symptoms.  She is unable to eat, and her reflux symptoms were initially treated with omeprazole which about 40% improvement.  She did develop severe diarrhea, so she discontinued use.  She changed her medications to include Nexium which also caused diarrhea.  She has undergone an upper endoscopy showing no H. (helicobacter) pylori, celiac's disease or Barrett's esophagus.  There was no mention of a hiatal hernia.  She also underwent a barium swallow study showing esophageal reflux.  The documentation indicated she did undergo an additional EGD with pH testing.  She was noted to have a Hill grade 1 on retroflexed view of the cardia.  The Bravo according to the physician was positive for reflux by DeMeester score.  She has been utilizing Dexilant 60 mg with improved symptoms.  She however does not want to continue use of medications.  It was recommended she undergo surgical intervention. 

The procedure is Food and Drug Administration (FDA) approved and included in American Gastroentrological Association (AGA) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) (medical and surgical guidelines). There are guidelines supporting the use of Transoral incisionless fundoplication (TIF) for patients with gastroesophageal symptoms like this patient.  This procedure is especially beneficial for this patient with regurgitation (vomiting). Regurgitation is not alleviated by medical therapy and an endoscopic procedure like TIF will offer more benefit than medical treatment. These less invasive endoscopic procedures are standard of care in lieu of surgical fundoplication. 

This is better than open surgical procedure with less morbidity and faster recovery. The adverse risks are not increased over standard therapies this procedure is likely to be more beneficial than any standard procedures. 

The carrier's denial of procedure code 43210 to treat heartburn (transoral incisionless fundoplication procedure using the EsophyX) should be overturned.