Barrett's Esophagus denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 65-year-old male with a history of gastroesophageal reflux disease (GERD) who continues to be symptomatic despite high dose Nexium 40mg twice daily. The patient complains of burning and tightness in his throat and chest. Pathology revealed evidence of possible Barrett’s esophagus. Wireless Bravo pH capsule testing was requested to evaluate his symptoms of esophageal reflux disease, and to tailor his acid reflux therapy based upon the results of the Bravo pH study. At issue is whether the Bravo pH capsule testing is likely to be more beneficial for treatment of the patient’s condition than any available standard therapy.The wireless Bravo pH monitoring system is now considered the standard of care for the evaluation of patients with suspected or possible gastroesophageal reflux disease (GERD).

An enrollee has requested reimbursement for four Barrx Ablation Procedures that have been performed, and has requested authorization and coverage for the Barrx ablation procedure. Patients with family history of esophageal cancer have a predilection for esophageal cancer themselves. The risk of esophageal cancer in a patient with two first-degree relatives who have esophageal cancer (defined as familial Barretts esophagus) increases markedly, by over ten-fold in some studies. Expert opinion on ablation of non-dysplastic Barretts recommends ablation in patients with family history of esophageal cancer. The American Society of Gastrointestinal Endoscopy considers ablation to be a preferred management option in patients with family history of esophageal cancer.

Where the denial was upheld

Physician 1The patient is a 54-year-old man with long-standing gastroesophageal reflux disease (GERD) whose symptoms are largely controlled on Aciphex 20mg twice a day. His complaint is of breakthrough symptoms when supine at night. The patient has Barrett’s esophagus (without dysplasia) and has an elevated acid exposure on 24-hour pH testing. He does not have a large hiatal hernia. The patient consulted with his gastroenterologist regarding endoscopic treatments for GERD and an Enteryx procedure was recommended. The Health Plan has denied authorization and coverage for an Enteryx procedure on the basis it is considered investigational for treatment of GERD.The Enteryx procedure involves the injection of ethylene vinyl alcohol copolymer (EVOS) and dimethylsulfoxide (DMSO) into the gastroesophageal junction.

Nature of Statutory Criteria/Case Summary: An enrollee has requested LINX esophageal sphincter augmentation device for treatment of the enrollee’s Barrett’s esophagus, hiatal hernia, and gastroesophageal reflux disease (GERD). Findings: Two physician reviewers found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other standard surgical anti-reflux procedures. One evidence review concluded that “the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined” (Sheu and Rattner). Another evidence review concluded that “further studies are required to determine its long-term outcomes and its relative efficacy as compared to other established treatments” (Loh, et al). Adverse events, such as erosion through the esophagus, have been reported since U.S.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving barrett's esophagus, then check the rights and deadlines that apply to your plan.