This policy version was replaced on March 28, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).
The esophageal magnetic ring is a device designed to restrict the flow of stomach contents back into the esophagus, thereby improving the heartburn symptoms and reflux associated with gastroesophageal reflux disease (GERD). The ring-shaped device is implanted laparoscopically at the gastroesophageal junction and is comprised of a series of titanium beads, each with a magnetic core. The magnetic attraction between the beads is intended to augment the lower esophageal sphincter to prevent gastric reflux into the esophagus. It is proposed that swallowing foods or liquids creates sufficient pressure to overcome the magnetic bond between the beads, allowing food and liquids to pass normally into the stomach.
The LINX™ Reflux Management System has received premarket approval (PMA) from the U.S. Food and Drug Administration (FDA) for use in patients diagnosed with GERD, as defined by abnormal pH testing, who continue to have chronic GERD symptoms despite maximum therapy for the treatment of reflux.
Definitions
Esophageal sphincter: A circular band of muscle that closes the last few centimeters of the esophagus, preventing the backward flow of stomach contents.
Use of an implantable magnetic esophageal ring to treat gastroesophageal reflux disease (GERD) is considered EXPERIMENTAL/INVESTIGATIVE due to a lack of evidence demonstrating an impact on improved health outcomes.
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No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.
