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
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Diagnosis Codes
Covered Diagnosis Codes for Procedure Code 43257, 43210