Device Therapies for Gastroesophageal Reflux Disease (GERD)

This policy covers transendoscopic device therapies for GERD—primarily transesophageal endoscopic gastroplasty/transoral incisionless fundoplication (e.g., EsophyX, StomaphyX, MUSE) and radiofrequency Stretta—for treatment of symptomatic chronic GERD. Coverage is limited to adults ≥18 with confirmed GERD (endoscopy, pH monitoring or barium), ≥1 year of symptoms with frequent reflux, daily PPI use >6 months, BMI ≤35, no altered esophageal anatomy or motility disorder, hiatal hernia ≤2 cm, and other specified criteria; procedures not meeting all criteria, patients with severe esophagitis (LA C/D), Barrett’s >2 cm, achalasia, or use of injectable/bulking prostheses (e.g., Durasphere, Gatekeeper, PMMA, hydrogel) are excluded as investigational, and final coverage is subject to the member’s benefit plan and applicable state rules.

"Transendoscopic therapy (transesophageal endoscopic gastroplasty / transoral incisionless fundoplication [TIF] e."