HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
S-145-020
Topic:
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD)
Section:
Surgery
Effective Date:
December 25, 2017
Issued Date:
October 1, 2018
Last Revision Date:
September 2018
Annual Review:
September 2018
 
 

A variety of transesophageal endoscopic therapies have been developed for the treatment of GERD. These include: suture plication of the proximal gastric folds, injection of bulking agents or implantation of a bioprosthesis into the lower esophageal sphincter implantation of titanium beads with magnetic cores and radiofrequency energy.

The Stretta procedure uses radiofrequency energy to treat GERD and involves insertion of a flexible balloon-tipped catheter with needle electrodes for energy delivery via the esophagus. Precisely controlled radiofrequency energy is delivered to create lesions in the smooth muscle of the gastroesophageal junction.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

The following transendoscopic therapies for the treatment of GERD are considered experimental/investigational and therefore non-covered.  The long-term efficacy of these procedures has not yet been established.

  • Endoscopic/endoluminal gastroplasty, gastroplication with suturing of the esophagogastric junction (e.g. EndoCinch and Muse); and
  • Transoral incisionless fundoplication (TIF) (e.g. StomaphyX, EsophyX); and
  • Endoscopic submucosal implantation of a prosthesis or injection of a bulking agent (e.g., polymethylmethacrylate beads, zirconium oxide spheres, Enteryx, Durasphere®, Gatekeeper Reflux Repair System).

43210



Transesophageal endoscopic radiofrequency therapy (Stretta) may be considered medically necessary for a select population of patients, who are greater than or equal to 18 years of age with refractory GERD, who meet ALL of the following criteria:

  • Daily heartburn or regurgitation for greater than six (6) months; and
  • Unsuccessful or partial response to anti-secretory pharmacologic therapy; and
  • Have adequate esophageal peristalsis; and
  • Have a 24-hour pH study demonstrating pathologic acid reflux (total acid exposure time greater than four (4%) percent, or a DeMeester composite score greater than 14.7); and
    • Have non-erosive reflux disease; or
    • Have grade I and II esophagitis by Savary-Miller criteria, or have grades of esophagitis healed by drug therapy.

Contraindications:

  • Greater than 2cm hiatal hernia; or
  • Significant dysphagia; or
  • Incomplete lower esophageal sphincter relaxation.

The use of transesophageal endoscopic radiofrequency is considered experimental/investigational, and therefore, non-covered for all other indications. Peer reviewed literature does not support the use of transesophageal endoscopic radiofrequency for any indications other than those listed in this medical policy.

43257



Table Attachment

S-145

Savary-Miller classification of reflux esophagitis.

Grade 1: Single erosion above gastro-esophageal mucosal junction.

Grade 2: Multiple, non-circumferential erosions above gastro-esophageal mucosal junction.

Grade 3: Circumferential erosion above mucosal junction.

Grade 4: Chronic change with esophageal ulceration and associated stricture.

Grade 5: Barrett's esophagus with histologically confirmed intestinal differentiation within columnar epithelium.

Related Policies

Refer to Table Attachment for Savary-Miller classification of reflux esophagitis.

Refer to medical policy G-24 bariatric surgery for morbid obesity for additional information.

Refer to medical policy HMK M-77 Upper Gastrointestinal Endoscopy/Esophagoscopy for additional information.

Refer to medical policy HMK S-4 Endoscopic Procedures and Related Services for additional information.

Refer to medical policy S-233 Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease for additional information.


Covered Diagnosis Codes for Procedure Code 43257

K21.0

K21.9

 

 

 

 

 


Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Transesophageal endoscopic therapies for GERD is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.




    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.