Medical Policy
Effective Date:12/07/2011 Title:Transesophageal Therapy for GERD: Endoscopic Radiofrequency
Revision Date:08/06/2015 Document:BI327:00
CPT Code(s):43257
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. Radiofrequency thermal destruction of tissue has been applied to the lower esophageal sphincter to treat gastro esophageal reflux disease. 
  2. This technique has not been demonstrated to improve health outcomes and is not covered.
Medical Statement

Endoscopic application of radiofrequency energy treatment to the lower esophageal sphincter, using the Stretta device or any other, for the treatment of gastro esophageal reflux disease is considered experimental/investigational and is not covered.

 

 

Codes Used In This BI:

43257 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastro esophageal reflux disease
Limits
Intentially left empty
Reference

American Gastroenterological Association. (2008) American Gastroenterological Association Medical Position Statement on the Management of Gastro esophageal Reflux Disease. Gastroenterol, 2008; 135:1383-91.

Corley DA, Katz P, Wo JM, et al. (2003) Improvement of gastro esophageal reflux symptoms after radiofrequency energy: a randomized sham-controlled trial. Gastroenterology. 2003; 125(3):668-676.

Hogan WJ. (2001) Endoscopic treatment modalities for GERD: Technologic score or scare. Gastro Endosc 2001; 53:541-5 (editorial).

Kahrilas PJ. (2003) Radiofrequency therapy of the lower esophageal sphincter for treatment of GERD. Technological review. Gastrointest Endosc 2003; 57:723-31.

The Stretta procedure for GERD. The Med Letter Drugs Therap, 2006; 48:99-100.

Triadafilopoulos G, Dibaise JK, et al. (2001) Radiofrequency energy delivery to the gastro esophageal junction for the treatment of GERD. Gastro Endosc 2001; 53:541-5.

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