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

The patient is a male with medically refractory GERD (gastroesophageal reflux disease). The request is for magnetic sphincter augmentation. The patient has a history of GERD (gastroesophageal reflux disease) symptoms for over 5 years that are uncontrolled despite being on Prilosec 40mg (milligrams) BID (twice daily), famotidine, and carafate QID (four times per day). He had a GES (gastric emptying scintigraphy) that was normal, an EGD (esophagogastroduodenoscopy) that showed gastritis, an UGI (upper gastrointestinal series) showing a small hiatal hernia and reflux, manometry that was normal with 93% normal peristalsis, and a pH (potential of hydrogen) study showing GERD (gastroesophageal reflux disease) with a Demeester score of 17.2. Previously, the case was denied stating it was experimental/investigational, that it has not been proven medically effective, and it does not "have enough proof in the medical information or research by specialists that describe safety, value, or effectiveness."

Yes, the insurance plan should cover magnetic sphincter augmentation.
Magnetic sphincter augmentation should be a covered treatment for this patient. There are good data supporting the use of magnetic sphincter augmentation for medically refractory GERD (gastroesophageal reflux disease) (see references). Thus, this procedure can no longer be considered experimental/investigational. Additionally, major foregut societies recommend its use, as outlined below:

Sages (Society of American Gastrointestinal and Endoscopic Surgeons) technology and value assessment committee "safety and effectiveness analysis of the LINX reflux management system": "The LINX device has been demonstrated to result in long-term GERD (gastroesophageal reflux disease) control based on symptomatic outcomes, PPI (proton pump inhibitor) utilization, and pH (potential of hydrogen) studies, and "should be covered and reimbursed by insurance for appropriate patients."

ASGS (American Society of General Surgeons) "LINX statement in support from ASGS [American Society of General Surgeons]": "based on currently available information and the experience of our members with the procedure, we do support the LINX procedure as a mechanism for controlling GERD [gastroesophageal reflux disease] when it is placed by properly trained laparoscopic surgeons with experience in foregut surgery in the management of GERD (gastroesophageal reflux disease) patients."

Yes, the LINX procedure is more beneficial.
The patient has failed maximal medical therapy with max dose PPI (proton pump inhibitor), H2 (histamine H2-receptor) blocker, and Carafate. Surgery with magnetic sphincter augmentation is indicated here, and it has a lower side effect profile than traditional fundoplication (see references).