LCD/NCD Portal

NCD100.9

 

IMPLANTATION OF ANTI-GASTROESOPHAGEAL REFLUX DEVICE

 

 

Effective Date of this Version

6/22/1987

 

Benefit Category

• Physicians' Services.

• Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

 

Item/Service Description

• The implantation of an anti-gastroesophageal reflux device is a surgical procedure for the treatment of gastroesophageal reflux, a condition in which the caustic contents of the stomach flow back into the esophagus.

• The procedure involves the implantation of this special device around the esophagus under the diaphragm and above the stomach, which is secured in place by a circumferential tie strap.

 

Indications and Limitations of Coverage

The implantation of this device may be considered reasonable and necessary in specific clinical situations where a conventional valvuloplasty procedure is contraindicated.

The implantation of an anti-gastroesophageal reflux device is covered only for patients with documented severe or life threatening gastroesophageal reflux disease whose conditions have been resistant to medical treatment and who also:

• Have esophageal involvement with progressive systemic sclerosis; or

• Have foreshortening of the esophagus such that insufficient tissue exists to permit a valve reconstruction; or

• Are poor surgical risks for a valvuloplasty procedure; or

• Have failed previous attempts at surgical treatment with valvuloplasty procedures.

 

 

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