Savary-Miller classification of reflux esophagitis:
Grade 1: Single erosion above gastro-esophageal mucosal junction
Grade 2: Multiple, non-circumferential erosions above gastro-esophageal mucosal junction
Grade 3: Circumferential erosion above mucosal junction
Grade 4: Chronic change with esophageal ulceration and associated stricture
Grade 5: Barrett’s esophagus with histologically confirmed intestinal differentiation within columnar epithelium.
The use of transesophageal endoscopic radiofrequency is considered experimental/investigational, and therefore, non-covered for all other indications. Peer reviewed literature does not support the use of transesophageal endoscopic radiofrequency for any indications other than those listed in this medical policy
Covered Diagnosis Codes for Procedure Code 43257, 43210