About this policy
The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L34659. Benefits are not available for endoluminal treatment for Gastroesophageal Reflux Disease (GERD) using the Stretta® procedure, the Bard EndoCinch™ Suturing System, Plicator™, or similar treatments as these procedures are not considered reasonable and necessary for the diagnosis or treatment of an injury or disease. Currently, these procedures are considered non-covered due to the fact that current peer-reviewed literature does not support the efficacy of the services. Claims will be denied as “not proven effective.” Coverage is appropriate for the TIF (Transoral Incisionless Fundoplication) procedure, example EsophyX™, documentation must support the indications listed in L34659. Documentation Requirements The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See the Coverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, and any other records that describe or support the evaluation and treatment of the patient. Documentation should be available to the Contractor upon request.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.