Appeal type: Medical necessity
Decision: Overturned

Diagnosis: GERD 

Treatment: Esophageal Sphincter Augmentation with assistant surgeon services using CPT code 43284- Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band), including cruroplasty.

The insurer denied the Esophageal Sphincter Augmentation with assistant surgeon services fusing CPT code 43284- Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band), including cruroplasty. The denial was reversed.

This is a female patient who underwent laparoscopic repair of a hiatal hernia, laparoscopic placement of LINX device and laparoscopic anterior gastropexy in early 2019. The patient has symptomatic type 3 par-esophageal hiatal hernia complicated by severe gastroesophageal reflux disease (GERD) and asthma like symptoms. As per the operative note, the patient considered all options of therapy and elected to undergo placement of LINX, in addition to the repair of her hiatal hernia and gastropexy. The patient was originally seen in mid-2018 with long history of GERD with asthma symptoms. Documentation from mid-2018 indicated that an upper gastrointestinal series (UGI) showed a moderate large hiatal hernia with approximately one third of the stomach up within the chest. Additionally, documentation from late 2018 indicated that a 24 hour Bravo test showed abnormal DeMeester score consistent with symptomatic reflux. There was symptom correlation to heartburn, but not regurgitation. Manometry showed good esophageal body function with a normal lower esophageal sphincter. The provider felt she did require repair with laparoscopy vs open hiatal hernia repair with anterior gastropexy and placement of LINX procedure. An UGI indicated free gastroesophageal reflux to the level of the clavicles and a prominent hiatal hernia. An esophagogastroduodenoscopy (EGD) both performed mid - 2018 showed a large hiatal hernia with gastritis. Ambulatory pH monitoring study from late 2018 showed a DeMeester score of 26.4. High resolution esophageal motility study showed normal peristalsis with normal lower esophageal sphincter (LES) relaxation. A biopsy of the stomach in late 2018 showed a gastric polyp.

Based upon the information provided, the surgical esophageal sphincter augmentation procedure, with assistant surgeon services using CPT code 43284- laparoscopy surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e. magnetic band), including cruroplasty when performed was medically necessary for this patient. The procedure does improve health outcomes and it is safe and effective. The LINX has been recognized by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the American Society of General Surgeons (ASGS) as an option for treating GERD. Additionally, the Food and Drug Administration (FDA) updated the instructions for use (IFU) precaution in 2018 to establish the effectiveness of LINX in patients with hiatal hernia >3 cm.  There are long term results out to 5 years with improvement in the health outcomes for patients undergoing the LINX procedure. 

Based on the above, the medical necessity for surgical esophageal sphincter augmentation with assistant surgeon services using CPT code 43284- Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band), including cruroplasty when performed is substantiated. The insurer's denial is reversed.