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.
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.
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:
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.
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.
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
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.
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