43631
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
23.90
Facility
$1355.74
Non-Facility
$1355.74
Documentation Required
- Informed consent documenting discussion of limited long-term data, alternative treatments (medical therapy and fundoplication), and potential device-specific risks (dysphagia, need for dilation or removal, rare erosion/migration).
- Confirmatory evidence of pathologic GERD (examples across studies: pre-operative pH study confirming GERD; impedance-pH monitoring used to assess reflux and to determine cross-over eligibility in randomized trials).
- Exclusion of achalasia and assessment of esophageal peristaltic function (manometry) prior to candidacy for invasive anti-reflux procedures. (Best Practice Advice 14)
- Pre-operative evaluation described for LINX after sleeve gastrectomy: barium swallow, endoscopy with pH monitor and esophageal motility.
Key Coverage Criteria
- Patients with GERD with moderate-to-severe regurgitation, especially despite once-daily PPI treatment, should be considered for minimally invasive treatment with MSA rather than increased PPI therapy.
- In patients with proven GERD, laparoscopic fundoplication and magnetic sphincter augmentation are effective surgical options, and transoral incisionless fundoplication is an effective endoscopic option in carefully selected patients. (Best Practice Advice 12)
- In patients with proven GERD, Roux-en-Y gastric bypass is an effective primary anti-reflux intervention in obese patients, and a salvage option in non-obese patients. (Best Practice Advice 13)
- Candidacy for invasive anti-reflux procedures includes confirmatory evidence of pathologic GERD, exclusion of achalasia, and assessment of esophageal peristaltic function. (Best Practice Advice 14)
- MSA (LINX) may be used as an alternative to Roux-en-Y gastric bypass (RYGB) conversion in managing refractory post-sleeve gastrectomy (post-SG) reflux (small case series reported promising results but called for validation).
- MSA for treatment of medically-refractory gastroesophageal reflux after sleeve gastrectomy (described as a technically feasible option with improved LES resting pressure and esophageal acid exposure in preliminary reports).
5 Active Policies
CIGNA-0051 — Bariatric Surgery and Procedures - (0051)
AETNA-CPB-0213 — Gastroesophageal Reflux Disease (GERD): Treatments
AETNA-CPB-0327 — Infertility
AETNA-CPB-0707 — Headaches: Invasive Procedures
REGENCE-SUR186 — Gastroesophageal Reflux Surgery
Related Codes
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