Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-145
Topic: Endoscopic Gastroplasty or Gastroplication with Suturing of the Esophagogastric Junction
Effective Date: January 1, 2007
Issued Date: January 1, 2007
Date Last Reviewed: 12/2006

General Policy Guidelines

Indications and Limitations of Coverage

The long-term efficacy of endoscopic gastroplasty or gastroplication with suturing of the esophagogastric junction has not yet been established. Therefore, endoscopic gastroplasty or gastroplication with suturing of the esophagogastric junction is considered experimental/investigational, and is not covered.  A participating, preferred, or network provider can bill the member for the denied service.

Description

Endoscopic gastroplasty, also referred to as gastroplication with suturing of the esophagogastric junction is a minimally invasive alternative to either open or laparoscopic gastric fundoplication as a treatment of gastroesophageal reflux disease (GERD). During the upper gastrointestinal endoscopy, the physician suctions two sections of the esophageal-gastric tissue into the suturing system, deploys a needle with a suture, and tightens a running suture through the two portions of captured tissue to form a pleat or internal plication. The sutures are placed in the lower esophageal sphincter, thereby creating a functional antireflex barrier. These plications are designed to strengthen and lengthen the sphincter in order to decrease reflux. The Bard EndoCinch Suturing System is an example of a device used in endoscopic gastroplasty with suturing. This procedure is generally performed outpatient, does not require general anesthesia and takes approximately 30-35 minutes.

The Sew-Right (Wilson-Cook, Winston-Salem, NC) device is another type of endoscopic suture system that forms plication folds between proximal gastric rugae.  This sewing procedure is reported to be easier and requires fewer repetitive steps to place a suture compared with similar methods.

A recent variation of the endoscopic suturing system is the NDO Transmural Plicator.  This plicator creates a transmural, full-thickness plication using a pre-tied, suture based implant that is delivered endoscopically just below the gastrointestinal junction (GEJ) in a retroflexed manner to accentuate and restore the valvular mechanism.  This procedure is reported to take approximately 20 minutes to perform.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes


Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits or a contract.  Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

12/2001, Endoscopic gastroplasty or gastroplication with suturing of the esophagogastric junction

References

Endoscopic Gastroplasty for Gastroesophageal Reflux Disease, Gastrointestinal Endoscopy, Volume 51, No. 4, 04/2000

Transoral Endoscopic Suturing for Gastroesophageal Reflux Disease: A Multicenter Trial, Gastrointestinal Endoscopy, Volume 51, No. 4, 04/2000

Endoscopic and Endoluminal Techniques for the Control of Gastroesophageal Reflux: Are They Ready for Widespread Clinical Application?, Gastrointestinal Endoscopy, Volume 52, No. 6, 12/2000

Case-Control Comparison of Endoscopic Gastroplication with Laparoscopic Fundoplication in the Management of Gastroesophageal Reflux Disease: Early Symptomatic Outcomes, Surgical Laparoscopic Endoscopy Percutaneous Technology, Volume 12, No. 4, 08/2002

Endoscopic Anti-Reflux Procedures, Gastrointestinal Endoscopy, Volume 56, No. 5, 11/2002

National Blue Cross Blue Shield Association Medical Policy 2.01.38, Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease, 04/2004

Clinical Presentation, Diagnosis, and Management of Gastroesophageal Reflux Disease, Medical Clinics of North America, Volume 89, No. 2, 03/2005

Managing Gastroesophageal Reflux Disease for the Lifetime of the Patient: Evaluating the Long-Term Options, American Journal of Medicine Supplements, Volume 117, No. 5A, 09/2004

Endoscopic Full-Thickness Plication for the Treatment of GERD: A Multi-Center Trial, Gastrointestinal Endoscopy, Volume 59, No.2, 02/2004

View Previous Versions

[Version 001 of S-145]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.