Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Gastroesophageal Reflux Disease/GERD.
Treatment: Surgical Services.
The health plan denied the requested procedure as not medically necessary. 
The health plan's determination is overturned.

The patient is a female under evaluation and management for acid reflux disease. The patient's last esophagogastroduodenoscopy (EGD) showed a small hiatal hernia and Grade A esophagitis. She is negative for Barrett's esophagus and H pylori. On once daily proton pump inhibitor (PPI) she has good symptom control. She would like to avoid the theoretical long term side effects of PPI's.
The patient's provider has recommended the Stretta procedure (EGD with radiofrequency ablation (RFA)). This procedure was denied by the plan which considers it to be experimental/investigational.

I recommend overturning the health plan's denial, in whole.

Although the precise mechanisms of benefit in gastroesophageal reflux disease (GERD) are unclear, radiofrequency treatment appears to reduce postprandial transient lower esophageal sphincter relaxations and decrease compliance of the gastroesophageal junction, and may decrease esophageal acid sensitivity by inducing healing of esophageal erosive disease. [1]
Multiple studies have examined the efficacy of radiofrequency (RF) treatment for gastroesophageal reflux disease (GERD). Overall, 55 to 83 percent patients have reported satisfactory symptom control or cessation of proton pump inhibitor (PPI) use in studies with average follow-up periods of 12 to 33 months.[1]
In a systematic review and meta-analysis of 28 studies of over 2400 patients with GERD, scores for health-related quality of life and heartburn were improved in patients who underwent Stretta compared with patients in a sham treatment group [2]. The rate of PPI use was lower in patients who underwent radiofrequency treatment compared with rate of pre-procedure PPI use (49 vs 97%).
The efficacy of RF treatment was also examined in a meta-analysis of 18 randomized trials, cohort studies, and reviews with 1441 patients performed over a 10-year span [3]. RF treatment improved heartburn scores and quality of life. Esophageal acid exposure was lower following the procedure compared with baseline but did not normalize. There was also a trend toward improved lower esophageal sphincter pressure.
Studies with long-term follow-up have found radiofrequency treatment to be effective. The durability of radiofrequency treatment was assessed in 26 patients who were followed for eight years [4]. At eight years, 77 percent of patients were completely off PPIs [4]. In a second study with 217 patients with refractory GERD who underwent RF treatment, normalization of GERD health-related quality of life seen in 72 percent of patients at 10 years [5]. Secondary outcomes were 50 percent reduction or elimination of PPIs, and 60 percent or greater improvement in satisfaction at 10 years. A 50 percent or greater reduction in PPI use occurred in 64 percent of patients (41 percent eliminating PPIs entirely), and a 60 percent or greater increase in satisfaction occurred in 54 percent of patients [5].
Overall, the bulk of the data supports the efficacy of the Stretta procedure.