43289
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- No explicit documentation requirements are specified in the provided policy text chunk. Note: Clinical evidence summaries and device FDA indications cited in the policy reference use of diagnostic tests in trials (e.g., esophageal pH testing, manometry, pathologic esophageal acid exposure, hiatal hernia size) but the policy text does not list these as formal documentation requirements for coverage in this excerpt. Documentation of 'careful discussion with the patient regarding potential adverse effects, benefits, and other available therapeutic options' when considering endoscopic antireflux therapy (ASGE recommendation). For TIF/EsophyX: documentation that patient has symptomatic chronic GERD, 'requires and responds to pharmacologic therapy', has not obtained satisfactory relief from a standard dose of PPI therapy OR wishes to avoid lifetime drug therapy, and documentation of hiatal hernia size ≤ 2 cm where applicable (ASGS / EsophyX device labeling). For Stretta: documentation that patient is >18 years old; has heartburn/regurgitation symptoms for ≥6 months; has been partially or completely responsive to anti-secretory pharmacologic therapy; and has declined laparoscopic fundoplication (SAGES criteria). For LINX and other implantable devices: documentation of clinician/surgeon training and experience in laparoscopic foregut surgery and management of GERD; documentation of patient selection criteria and informed consent regarding device-specific risks (erosion, dysphagia, need for dilation/explanation). For POEM or other achalasia interventions: documentation of achalasia subtype, prior treatment(s) (if any), rationale for chosen therapy (POEM vs Heller vs pneumatic dilation), and consideration of local expertise and patient preference (SAGES / ASGE guidance). For EndoFLIP: documentation showing EndoFLIP used as an adjunct to other diagnostic methods as part of a comprehensive evaluation of patients with symptoms consistent with gastrointestinal motility disorders (per device labeling). Documentation of trials of lifestyle modification and 'optimal medication use' (including PPI therapy) and confirmation of PPI-refractory GERD when relevant (AGA clinical practice update guidance). Administrative/documentation requirement: check member-specific benefit plan and any applicable federal/state mandates; in absence of Medicare NCD/LCD, MAO may apply its own coverage determinations — documentation should reference applicable plan/NCD/LCD if used to support coverage.
Key Coverage Criteria
- Per oral endoscopic myotomy (POEM) procedure is proven and medically necessary for treating individuals with Achalasia or Diffuse Esophageal Spasm. AGA: Stepwise approach for individuals presenting with GERD symptoms; when symptoms persist despite lifestyle changes and optimal medication use, management strategies should be tailored based on factors such as the integrity of the anti-reflux barrier, presence of visceral hypersensitivity and hypervigilance, confirmation of PPI-refractory GERD, sym [...]
- Stretta System: approved for radiofrequency thermal ablation treatment of GERD.
- Bard EndoCinch / NDO Plicator: approved for endoscopic suturing in treatment of GERD (historical approvals).
- EsophyX2: indicated for use in transoral tissue approximation; full-thickness plication and ligation in the GI tract; treatment of symptomatic chronic GERD in patients who require and respond to pharmacologic therapy; narrowing of the gastroesophageal junction; reduction of hiatal hernia <2 cm in patients with symptomatic chronic GERD.
- MUSE (Medigus Ultrasound Surgical Endostapler): indicated for creation of anterior partial fundoplication for treatment of symptomatic chronic GERD in patients who require and respond to pharmacologic therapy.
- EndoFLIP System: indicated to measure pressure and dimensions in the esophagus, pylorus, and anal sphincters; intended to be used as an adjunct procedure to other diagnostic methods as part of a comprehensive evaluation of patients with symptoms consistent with gastrointestinal motility disorders.
5 Active Policies
UHC-POL-minimally-invasive-procedures-gerd-achalasia — Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases
UMR-POL-UMR-minimally-invasive-procedures-gerd-achalasia — Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases
SUREST-POL-SUREST-minimally-invasive-procedures-gerd-achalasia — Minimally Invasive Procedures for the Treatment of Upper Gastrointestinal Diseases
CIGNA-POEM — Minimally Invasive Anti-Reflux Procedures and Peroral Endoscopic Myotomy (POEM) Procedures - (0019)
Related Codes
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