Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (LINX®)

Policy ID: S-233-012

Section: Surgery

Effective Date: July 01, 2018

Revised Date: July 02, 2024

Revision Effective Date: September 02, 2024

Last Reviewed: July 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

A laparoscopically-implanted ring composed of interlinked titanium beads with magnetic cores has been developed for the treatment of gastroesophageal reflux disease (GERD). The device is placed around the esophagus at the level of the gastroesophageal junction in individuals who have GERD symptoms despite maximum medical therapy.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; or

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

A laparoscopically implantable magnetic esophageal ring (LINX® Reflux Management System) may be considered medically necessary when ALL of the following conditions are met:

When used as an alternative treatment to surgical fundoplication; and
When the individual presents with gastroesophageal reflux disease (GERD) and is symptomatic two or more times per week; and
Who have GERD symptoms despite medical therapy or are intolerant to medical therapy.

Laparoscopically implantable magnetic esophageal ring (LINX® Reflux Management System) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer reviewed literature.

Procedure Codes

43284

43285

43289

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 43284 and 43285

G47.30

G47.31

G47.32

G47.33

J31.2

J37.0

J45.20

J45.21

J45.22

J45.30

J45.31

J45.32

J45.40

J45.41

J45.42

J45.50

J45.51

J45.52

J45.901

J45.902

J45.909

J45.990

J45.991

J45.998

J69.0

J82.83

K20.80

K20.81

K20.90

K20.91

K21.00

K21.01

K21.9

P28.0

P28.10

P28.11

P28.19

P28.2

P28.3

P28.4

P28.5

P28.81

P28.89

P28.9

R00.1

R0.5

R06.1

R06.2

R06.81

R07.89

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2020 Coding update:

Removed K21.0 and
Added K21.00 and K21.01.

Internal Medical Policy Committee 9-21-2021 Annual Review-no changes in criteria

Internal Medical Policy Committee 11-23-2021 Revision

Updated in clarifying language.

Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 02, 2022

Removed Procedure code 43289
Added Diagnosis codes G47.30; G47.31; G47.32; G47.33; J31.2; J37.0; J45.20; J45.21; J45.22; J45.R06.130; J45.31; J45.32; J45.40; J45.41; J45.42; J45.50; J45.51; J45.52; J45.901; J45.902; J45.909; J45.990; J45.991; J45.998; J69.0; J82.83; K20.80; K20.81; K20.90; K20.91; P28.0; P28.10; P28.11; P28.19; P28.2; P28.3; P28.4; P28.5; P28.81; P28.89; P28.9; R00.1; R0.5; R06.1; R06.2; R06.81 and R07.89.

Internal Medical Policy Committee 7-26-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 7-16-2024 Coding update - Effective September 02, 2024

Added procedure code 43289 back into policy as it was removed in error; and
Added Policy Application.

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.