GERD Procedure denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee requested coverage for laparoscopic placement of an esophageal sphincter augmentation device (LINX) and cruroplasty. The record indicates the enrollee has gastroesophageal reflux disease and esophagitis. Medications have included ondansetron, famotidine, hycosamine, Dexilant and aluminum magnesium hydroxide. The UGI (upper gastrointestinal series) performed revealed esophageal dysmotility, with increased gastroesophageal junction transit time and a small hiatal hernia without evidence of gastroesophageal reflux. The Bravo pH testing revealed a DeMeester score of 61.5. The findings strongly support a diagnosis of excessive gastroesophageal acid reflux and substantiate an excellent correlation between symptoms of chest pain, regurgitation and reflux of acid.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic esophageal sphincter augmentation. In this case, the records document the patient’s incomplete response to standard medical therapy, long term symptoms, and incomplete response to proton pump inhibitors (PPIs). Notes reported a history of irritable bowel syndrome since age 18. The patient’s was started on PPI therapy for treatment of primary symptoms of gastroesophageal reflux disease (GERD). The patient had lost 45 pounds over the past few years and her symptoms remained unchanged despite taking omeprazole, Pepcid, and TUMS. The records noted that pH testing showed positive symptom correlation with heartburn, and that high resolution manometry showed normal motility. The patient reported daily reflux. Notes reported continued symptoms refractory to PPI therapy.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic anti-reflux surgery utilizing the LINX Reflux Management System.Findings: Two out of three physician reviewers found that the requested laparoscopic anti-reflux surgery utilizing the LINX Reflux Management System is not likely to be more beneficial than any available standard treatment for the patient’s medical condition.Researchers conducted a controlled clinical trial and concluded that sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits as demonstrated by reduced esophageal acid exposure, improved GERD-related quality of life, and cessation of dependence on PPIs, with minimal side effects and no safety issues.

A patient has requested authorization and coverage for transoral incisionless fundoplication. The Health Plan has denied this request, indicating that the requested services are investigational for the treatment of the patient’s gastroesophageal reflux disease. A review of the record indicates that the patient has been diagnosed with irritable bowel syndrome, gastroesophageal reflux disease with esophagitis, diaphragmatic hernia without obstruction or gangrene, alcohol abuse, and other lactose intolerance. Abdominal ultrasound revealed no acute process. A distal esophageal biopsy was performed. The pathology report noted mild chronic esophagitis with features suggesting reflux. The results were negative for intestinal metaplasia, dysplasia or malignancy.

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 GERD Procedure, then check the rights and deadlines that apply to your plan.