Prior authorization required; covered CPTs if criteria met

Prior authorization is required. Submit clinical documentation with the prior authorization request. CPT 43210 and the unlisted laparoscopy procedure code 43659 are covered when the policy criteria for TIF are met.

• Covered CPTs when criteria met: 43210; 43659.
• Prior authorization must include supporting clinical documentation.

Comply with CMS NCDs/LCDs and Medicare Benefit Policy Manual

When applicable, providers must follow CMS guidance: compliance with National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and the Medicare Benefit Policy Manual is required; these determinations govern Medicare coverage.

• CMS resources: Medicare Benefit Policy Manual (Pub.100-2), Chapter 15, §50 and the CMS Coverage Database.
• Additional indications may be covered at the plan’s discretion.

Conservative therapy required before TIF

Members must have failed initial management (lifestyle/OTC) and have a history of daily proton pump inhibitor (PPI) therapy for greater than 6 months before TIF will be considered.

• Failure of initial therapy (lifestyle modifications/OTC) precedes PPI use.
• Documented daily PPI therapy duration: > 6 months.

Reference Medicare LCD/NCD guidance for Medicare patients

Follow applicable Medicare LCD guidance when requesting coverage for Medicare members; ensure prior authorization and documentation align with any LCD/NCD language that applies.

• Where NCDs/LCDs exist they govern Medicare coverage and may restrict coverage.
• Link to CMS Coverage Database provided in policy.

Prior authorization documentation required

Submit provider records of the physical exam and symptoms, prior treatments attempted, and prior medical history and surgeries/procedures related to GERD with the prior authorization request.

• Include physical exam findings and symptom history.
• List prior treatments attempted and pertinent surgical history related to GERD.

Use listed ICD-10 diagnosis codes on claims

Use the listed ICD-10 diagnosis codes when submitting claims for endoscopic GERD procedures: K21 (Gastro-esophageal reflux disease) or K21.9 (Gastro-esophageal reflux disease without esophagitis).

• Acceptable diagnosis codes: K21, K21.9.

Non‑TIF endoscopic GERD procedures are experimental/investigational

Requests for endoscopic procedures for GERD other than transoral incisionless fundoplication (TIF) are considered experimental and investigational and may be denied.

• Procedures considered experimental/investigational include (but are not limited to): Stretta System, EndoCinch, Enteryx, LINX (lap/open), StomaphyX, Full-Thickness Plicator, and others listed in the exclusions.

Noncompliance with Medicare coverage guidance may affect decisions

Failure to comply with applicable NCDs, LCDs, or Medicare Benefit Policy Manual guidance may affect coverage decisions for Medicare beneficiaries.

• NCDs/LCDs govern Medicare coverage where they exist and may restrict coverage.
• Ensure prior authorization and submitted documentation align with Medicare policies.