Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD
Treatment: Laparoscopic Esophageal Surgery and Hospital Admission (43284) (Pre-Service)
The insurer denied the Laparoscopic Esophageal Surgery and Hospital Admission (43284) (Pre-Service). 
The denial is overturned, in part.

This patient is a female with BMI 29.7 kg/m2 with symptomatic GERD (Gastroesophageal Reflux Disease) despite long term medication use. EGD revealed no Barrett's esophagus and a small hiatal hernia. 24 hour pH testing was positive for an elevated DeMeester score of 41 consistent with severe GERD. Manometry did not reveal evidence of achalasia. 

Yes, the health plan should cover the proposed LINX procedure and the related hospital admission, in part.

This patient has GERD 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 in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. The exclusions to LINX and nissen fundoplication include BMI >35 kg/m2 in which case treatment of obesity is thought to be important for treatment of GERD. Other exclusions for LINX include barrett's esophagus with dysplasia, age <18 and prior gastric or bariatric surgery. This patient has no exclusion to LINX treatment, a standard surgical option for treatment of GERD. The procedure can be performed at an outpatient or ambulatory level of care. Inpatient admission is not required. Therefore the recommendation is partial, approve the procedure but at a lower level of care (outpatient, ambulatory or observation) not inpatient level of care. 

Yes, the requested health service or procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease, in part.

The patient has failed medical management of GERD. LINX is considered a standard surgical treatment for GERD within the medical community and is recommended in updated published guidelines from the Society of Gastrointestinal and Endoscopic Surgeons to be a safe, effective and durable treatment for GERD for mid to long-term outcomes based on published findings. There are only a few exclusions to the treatment which include: Barrett's esophagus with dysplasia, age <18 years, prior bariatric or gastric surgery and BMI >35 kg/m2 of which this patient has none.  The treatment is comparable to other surgical reflux treatment (lap nissen fundoplication) with less morbidity and mortality. 

The procedure can be performed at an outpatient or ambulatory level of care. Inpatient admission is not required. Therefore the recommendation is partial, approve the procedure but at a lower level of care (outpatient, ambulatory or observation) not inpatient level of care.