Diagnosis: Digestive System/Gastrointestinal/Gastroesophageal Reflux Disease/GERD
Treatment: Surgical Services (All)
The health plan denied the requested surgical procedure as experimental/investigational.
The health plan's determination is upheld.

This patient is a male with a history of gastroesophageal reflux disease (GERD) and regurgitation. An esophagogastroduodenoscopy (EGD) reports a large hiatal hernia (HH) and esophagitis. Pathology did not reveal findings of intestinal metaplasia. Per medical records, the hiatal hernia is reported to be 6.8 cm (centimeters). Esophageal manometry was reported to be normal. A 24-hour potential hydrogen (pH) study revealed an elevated DeMeester score of 22.9, consistent with GERD.
At issue is whether the proposed health service or treatment of a LINX Reflux Management System is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The health plan's determination regarding the proposed health service is upheld, in whole.

No. This patient has GERD and regurgitation. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and the LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. Exclusions to LINX treatment include age < 18, pregnancy, metal allergy, body mass index (BMI)>35 kg/m2, HH > 3 cm, Barrett's esophagus with dysplasia and esophageal motility disorder. This patient has findings of a hiatal hernia that is reported to be very large on EGD and 6.8 cm in the medical records. A hiatal hernia of > 3cm is generally considered to be an exclusion to LINX treatment. LINX treatment has not been fully studied in situations of very large or gigantic hiatal hernias and this finding would be considered an exclusion to treatment.