Transoral Fundoplication (TIF 2.0) — Medical Necessity and Coverage Criteria
Customize your policy alerts
Sign up for Baylor Scott & White Health Plan Policy 227 alerts
Get alerted when Policy 227 changes without checking for updates manually.
Monitor payer policy activity
Defines medical necessity, inclusion and exclusion criteria, coding guidance, and authorization requirements for transoral incisionless fundoplication (EsophyX®/TIF 2.0) for Baylor Scott & White Health Plan members across lines of business.
Coverage expanded from Medicare-only to all lines of business with criteria-based medical necessity determination.
Added specific patient selection inclusion criteria, exclusion criteria, and documentation of required objective testing (pH monitoring, impedance, endoscopy, manometry).
Added coding guidance listing CPT and ICD-10 codes that may apply to TIF and related diagnostics.
Medical Necessity and Exclusion Criteria
Medical Necessity and Exclusion Criteria for TIF 2.0
Transoral fundoplication (EsophyX® TIF 2.0) may be considered medically necessary when ALL of the following are met:
Exclusion Criteria Summary
Any one of the following exclusions disqualifies the patient from TIF 2.0:
Procedure and Diagnosis Coding Guidance
| 43210 | Esophagogastroduodenoscopy; with esophagogastric fundoplasty partial or complete (TIF 2.0) |
| 43280 | Laparoscopy, surgical, esophagogastric fundoplasty (may apply to cTIF hiatal hernia repair component) |
| 43281 | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty when performed (may apply to cTIF) |
| 91034 | Esophagus, gastroesophageal reflux test (pH monitoring) |
| 91037 | Esophageal function test, intraluminal impedance |
| 91038 | Esophageal function test, intraluminal impedance, prolonged |
| 91010 | Esophageal motility study (manometry) |
| No codes listed |
| K21.0 | Gastro-esophageal reflux disease with esophagitis |
| K21.9 | Gastro-esophageal reflux disease without esophagitis |
| K44.9 | Diaphragmatic hernia without obstruction or gangrene |
| K20.8 | Other esophagitis |
| K20.80 | Other esophagitis without bleeding |
| K20.9 | Esophagitis, unspecified |
| R13.10 | Dysphagia, unspecified |
| R13.19 | Other dysphagia |
| K22.70 | Barrett's esophagus without dysplasia |
| K22.71 | Barrett's esophagus with dysplasia |
| No codes listed |
| No codes listed |
Authorization, Provider Requirements, and Exclusions
Prior Authorization Requirement
Prior authorization must be obtained for members covered under Commercial and Self-funded plans. Prior authorization is not required for Medicare and Medicaid lines of business; Medicare plans should follow applicable NCD/LCD when present.
- Check member's plan type (Commercial, Self-funded, Medicare, Medicaid) before scheduling.
- For Medicare, confirm if an applicable NCD or LCD applies; if none, use the policy criteria.
Provider Competency Requirement
The procedure must be performed by a surgeon or gastroenterologist who has documented training and competency in Transoral incisionless fundoplication (TIF 2.0).
- Include evidence of provider training/competency in the prior authorization or medical record as required.
Exclusion Criteria — Denial Risk (Any one disqualifies)
Any single listed exclusion disqualifies the patient from TIF 2.0; providers must verify and document absence of all exclusions before requesting authorization.
- Severe erosive esophagitis (LA grade C or D) — exclusion.
- Barrett's esophagus (any length) — exclusion.
- Esophageal stricture or significant dysmotility (including achalasia) — exclusion.
- Hiatal hernia > 2 cm or Hill grade III/IV anatomy — excludes standard TIF (consider cTIF if appropriate).
- BMI > 35 kg/m² — exclusion.
- Prior esophageal or gastric surgery (including prior fundoplication) — exclusion.
- Coagulopathy or anticoagulation that cannot be safely interrupted — exclusion.
- Active esophageal or gastric malignancy — exclusion.
Key Definitions and Thresholds
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.