Anthem Blue Cross ConnecticutCommercial Clinical Policy

SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD) Form

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Effective Date

09/27/2023

Last Reviewed

08/10/2023

Original Document

  Reference



This document addresses the use of non-endoscopic devices intended for the treatment of gastroesophageal reflux disease (GERD), including the LINX® Reflux Management System (Johnson and Johnson, New Brunswick, NJ). Such devices are surgically implanted in the vicinity of the lower esophageal sphincter (LES) to support and augment the function of the LES, with the goal of decreasing or stopping gastroesophageal reflux. This document does not address transendoscopic therapies for the treatment of GERD.

Note: Please see the following related documents for additional information:

  • SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
  • CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus

Position Statement

Investigational and Not Medically Necessary:

Lower esophageal sphincter augmentation devices are considered investigational and not medically necessary for the treatment of gastroesophageal reflux disease (GERD) and for all other indications.

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