Transesophageal endoscopic radiofrequency therapy (Stretta), or transoral incisionless fundoplication
All claims submitted for this policy 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. and/or
All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
Transesophageal endoscopic radiofrequency therapy (Stretta), or transoral incisionless fundoplication (TIF) (i.e., StomaphyX, EsophyX) may be considered medically necessary for a select population of individuals, who are greater than or equal to 18 years of age with refractory GERD, who meet ALL of the following criteria:
- Daily heartburn or regurgitation for greater than six (6) months; and
- Unsuccessful or partial response to anti-secretory pharmacologic therapy, have poor proton pump inhibitor (PPI) tolerance, or high concern for long term PPI use; and
- No specific motility disorder; and
- Evidence of reflux disease; and
- Either have a 24-hour pH study demonstrating pathologic acid reflux (total acid exposure time greater than four (4%) percent), or a DeMeester composite score greater than 14.7; or
- Have non-erosive reflux disease; or
- Have grade I and II esophagitis by Savary-Miller criteria or have grades of esophagitis healed by drug therapy.
Contraindications:
- Greater than two (2) cm hiatal hernia (unless simultaneous or prior repair of hiatal hernia is performed; or
- Significant dysphagia; or
- Incomplete lower esophageal sphincter relaxation.
Transesophageal endoscopic radiofrequency therapy or transoral incisionless fundoplication not meeting the criteria as indicated in this policy is considered not medically necessary.
Procedure Codes
