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201910-122062

2019

Empire Healthchoice HMO Inc.

HMO

Digestive System/ Gastrointestinal

Surgical Services

Experimental/Investigational

Overturned

Case Summary

Diagnosis: GERD
Issue under review: LINX procedure

Determination:
The health plan should cover the LINX procedure.

The health plan denied the request for Linx procedure calling the procedure experimental or investigational. It has not been experimental for many years.

This patient suffers from chronic GERD (gastroesophageal reflux disease). Surgical therapies exist that resolve this very well. Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended. Other techniques have been tried endoscopically and otherwise, but none of the others have been able to demonstrate long term efficacy and safety. The side effects of LNF make it a less than ideal operation. Linx is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term. It is approved by the FDA. There is published data on patients who have had the device for six years, showing a very low complication rate and a high resolution of GERD.

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