Medical Policy
Effective Date:02/03/2010 Title:Endoscopic/Transoral Fundoplication
Revision Date:01/01/2017 Document:BI262:00
CPT Code(s):43210, C9724
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    A procedure being used to treat esophageal reflux is Transoral Fundoplication using the Esophyx, Stomaphyx, or other like systems; this procedure is not covered.

2)    For use of radiofrequency thermal destruction therapy for GERD, see BI327.
Medical Statement

Transoral Fundoplication is considered experimental and investigational, as there is insufficient peer review evidence to support the effectiveness, especially for long term.

 

Codes Used In This BI:

 

C9724          Endoscopic full-thickness placation in the gastric cardia using endoscopic

                    application system (EPS); includes endoscopy (code deleted 1/1/16)

43210           EGD with esophagogastric fundoplasty
Limits

CPT code 43210 is not covered.
Reference

1.     Cadière GB, Rajan A, Germay O, Himpens J. Endoluminal fundoplication by a Transoral device for the treatment of GERD: A feasibility study. Surg Endosc. 2008; 22(2):333-342.

2.     U.S. Food and Drug Administration (FDA), Center for Devices and Radiologic Health (CDRH). EndoGastric Solutions Stomaphyx endoluminal fastener and delivery system. Summary of Safety and Effectiveness Information. 510(k) No. K062875. Rockville, MD: FDA; March 3, 2007.

3.     U.S. Food and Drug Administration (FDA), Center for Devices and Radiologic Health (CDRH). EndoGastric Solutions (EGS) Esophyx System with Serosa Fuse Fastener and accessories. 510(k) Summary. 510(k) No. K071651. Rockville, MD: FDA; September 14, 2007.

4.     Bergman S, Mikami DJ, Hazey JW, et al. Endoluminal fundoplication with Esophyx: The initial North American experience. Surg Innov. 2008; 15(3):166-170.

5.     Von Renteln D, Schiefke I, Fuchs KH, et al. Endoscopic full-thickness plication for the treatment of GERD by application of multiple Plicator implants: A multicenter study (with video). Gastrointest Endosc. 2008; 68(5):833-844.

6.     Pace F, Costamagna G, Penagini R, et al. Review article: Endoscopic antireflux procedures - an unfulfilled promise? Aliment Pharmacol Ther. 2008; 27(5):375-384.

7.     National Institute for Health and Clinical Excellence (NICE). Endoscopic radiofrequency ablation for gastro-oesophageal reflux disease. Interventional Procedure Guidance 292. London, UK: NICE; March 2009

8.     Hayes Medical Technology Directory.  Endoscopic therapy for gastro esophageal reflux disease.  Published 30 July 2015.  Accessed 3 August 2015.

9.     Witteman BP et al.  Randomized controlled trial of Transoral incision less fundoplication vs. proton pump inhibitors for treatment of gastro esophageal reflux disease.  Am J Gastroenterology.  2015 Apr; 110(4): 531-542.

Addendum:

Effective 01/01/2017:  Removed HCPCS Code C9724 from Claim Statement section.  This code was deleted effective 1/1/16.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.