Diagnosis: GERD (gastroesophageal reflux disease).
Treatment: LINX Reflux Management System (43284) and Inpatient Stay.
The insurer denied the LINX Reflux Management System (43284) and Inpatient Stay. The denial is overturned.

The patient is a man with belching, chest pain, early satiety, globus sensation, heartburn, a hoarse voice and a sore throat. He was found to have an ulcer at the GE (gastroesophageal) junction on upper endoscopy, elevated esophageal acid exposure on esophageal pH (potential of hydrogen) monitor, and normal motility on esophageal manometry and UGI (upper gastrointestinal series) revealed hiatal hernia. He was recommended to undergo laparoscopic hiatal hernia repair with LINX. He has tried Protonix 40 twice a day without benefit. He has tried elevating the head of bed and dietary changes.

Yes, the health plan should cover the LINX Reflux Management System (43284) and Inpatient Stay.

Yes, the LINX Reflux Management System (43284) and Inpatient Stay is likely to be more beneficial.

This patient suffers from GERD (gastroesophageal reflux disease) causing profound symptoms. Even with PPI (proton pump inhibitor) there is refluxing gastric contents. 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 have been able to demonstrate long term efficacy and safety. The side effects of LNF (Laparoscopic Nissen Fundoplication) 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 (Food and Drug Administration). There is published data on patients who have had the device for 12 years, showing a very low complication rate and a high resolution of GERD (gastroesophageal reflux disease). This operation commonly requires an inpatient stay to prevent postoperative nausea and vomiting, and to observe for bleeding, therefore the inpatient stay should be approved as well.