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

Policy ID: S-233-012

Section: Surgery

Effective Date: July 01, 2018

Revised Date: December 16, 2022

Revision Effective Date: January 02, 2023

Last Reviewed: July 26, 2023

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.

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

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

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.

Policy ID: S-233-010

Section: Surgery

Effective Date: July 01, 2018

Revised Date: September 29, 2020

Revision Effective Date: November 02, 2020

Last Reviewed: September 21, 2021

Archived Date: January 02, 2022

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 patients who have GERD symptoms despite maximum medical therapy.

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 patient 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.

Use of the laparoscopically implantable magnetic esophageal ring (LINX® Reflux Management System) for any other indication is considered experimental/investigational and therefore, non-covered. Peer reviewed literature does not support the use of laparoscopically implantable magnetic esophageal ring (LINX® Reflux Management System) for any other indication.

Procedure Codes

43284

43285

43289

Diagnosis Codes

K21.00

K21.01

K21.9

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

Links

References (PDF)

Disclaimer

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