Humana Achalasia and Gastroesophageal Reflux Disease (GERD) Treatments Form

Description

Achalasia is a rare smooth muscle disorder of the esophagus that is characterized by insufficient lower esophageal sphincter (LES) relaxation and loss of esophageal peristalsis. Symptoms include but may not be limited to: burning sensation in the chest (heartburn), chest pain, cough, regurgitation of undigested food and slowly progressive dysphagia.

Treatment is aimed at decreasing the resting pressure in the lower esophageal sphincter (LES), the ring of muscle between the esophagus and stomach, to a level at which the sphincter no longer impedes the passage of ingested material.

Achalasia and Gastroesophageal Reflux Disease Treatments

Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0335-023

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Treatments include, but may not be limited to:

• Botox therapy – For information regarding injection therapy, please refer to Botox (botulinum toxin) Pharmacy Coverage Policy.
• Myotomy (eg, Heller myotomy) is a procedure that involves the incision of the muscle fibers of the LES without disrupting the mucosal lining of the esophagus. It can be performed as an open or laparoscopic procedure.
• Pneumatic balloon dilation of the esophagus is performed by inflating a balloon that has been placed across the LES. It is intended to stretch or widen the esophageal muscle. This treatment may require repeated dilations to obtain improvement of symptoms.

GERD

Gastroesophageal reflux disease (GERD) is a digestive disorder that occurs when the stomach acids flow back up into the esophagus, which may cause indigestion, heartburn or esophagitis. Symptoms include, but may not be limited to belching, heartburn (usually after eating), chronic sore throat, difficulty when swallowing, dry cough, pain in the chest or regurgitation.

Treatments for GERD are designed to improve the function of the LES. The objectives are to eliminate symptoms, heal esophagitis and prevent recurrence of symptoms or progression of disease. Treatments for GERD include, but may not be limited to:

• Endoscopic plication or suturing which includes, but may not be limited to:endoscope that is inserted through the mouth. The system combines a miniaturized video camera, a surgical stapler and ultrasonic sights for alignment. It has been suggested that the use of this device can help restore a normal gastroesophageal valve through anterior fundoplication via endoluminally placed staples. (Refer to Coverage Limitations section)
• Transoral incisionless fundoplication (TIF) (eg, EsophyX) is an endoscopic procedure that is used to supposedly construct a durable antireflux valve. Using SerosaFuse Fasteners, the LES is reportedly tightened, which reestablishes a barrier to reflux and restores the competency of the gastroesophageal junction.

(Refer to Coverage Limitations section)

• Electrical stimulation of the lower esophageal sphincter (eg, EndoStim) is designed to stimulate an incompetent LES, which will reportedly strengthen the muscle and restore a functioning antireflux barrier between the stomach and esophagus. Electrical stimulation is delivered by electrodes that are implanted and sutured in the LES, which are attached to a programmable implantable pulse generator. The EndoStim device is not approved for sale in the United States (US) and is limited to investigational use only.

(Refer to Coverage Limitations section)

• Fundoplication (open or laparoscopic) is a surgical procedure in which the upper portion of the stomach (fundus) is wrapped around the lower end of the esophagus. Types of fundoplication procedures include, but may not be limited to:
• Nissen fundoplication is the most commonly used type of fundoplication in which the fundus of the stomach is wrapped completely around the lower end of the esophagus, which reinforces the LES with the goal of reducing the amount of acid that may back up into the esophagus.
• Partial fundoplication is created with the fundus partially enveloping the distal esophagus and was designed to create a reduction in postoperative dysphagia. Types of partial fundoplication procedures include, but may not be limited to:

1. 90° anterior partial fundoplication (APF) is a limited fundoplication procedure in which sutures are placed between the distal esophagus and the posterior hiatal pillar, which reportedly changes the angle of HIS. Sutures are also used to anchor the gastric fundus to the anterior esophagus and the fundal fold to the anterior esophagus.
2. Dor fundoplication is a procedure in which the fundus is partially wrapped around the distal esophagus and sutured to create a low-pressure valve. This is performed anteriorly and usually in an individual who also requires a Heller myotomy.
3. Hill repair is a procedure that attempts to change the antireflux barrier by reportedly reducing the hernia and anchoring the gastroesophageal junction by the normal attachment to the pre-aortic fascia recreating the gastroesophageal valve.
4. Lind partial fundoplication is performed by suturing the fundus to the esophagus at the left and right lateral positions as well as anteriorly on the left position.
5. Toupet fundoplication is a procedure that is similar to the Nissen fundoplication; however, this procedure utilizes a 270° wrap of the stomach around the lower esophagus rather than 360° that is used in the Nissen procedure. This may reduce the amount of pressure or compression that is placed on the lower esophagus as compared to the Nissen fundoplication, which may help those with impaired esophageal motility.

(Refer to Coverage Limitations section)

• Laparoscopic adjustable gastric banding (LAGB) (eg, LAP-BAND) involves the surgical insertion of a hollow band around the stomach near its upper end, creating a small pouch and a narrow passage into the larger remainder of the stomach. The band is inflated with a saline solution and can be tightened or loosened over time to change the size of the passage by increasing or decreasing the amount of saline. The procedure has been suggested to ease the symptoms of GERD.

(Refer to Coverage Limitations section)

• Magnetic sphincter augmentation (eg, LINX Reflux Management System) uses a small flexible band of interlinked titanium beads with magnetic cores that are laparoscopically placed around the esophagus, just above the stomach. The LINX system purportedly expands by swallowing, which allows food and liquid to pass normally into the stomach. The magnetic attraction then closes the LES, supposedly preventing reflux. (Refer to Coverage Limitations section)
• Roux-en-Y gastric bypass (RYGBP) (open or laparoscopic) is commonly known as gastric bypass. A small stomach pouch is created to restrict food intake. A Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum, and the first portion of the jejunum. This reduces the number of calories and nutrients the body absorbs. Long-limb RYGBP is similar to standard RYGBP, except that the limb through which food passes is longer, which purportedly eases symptoms of GERD. (Refer to Coverage Limitations section)

Esophageal disconnect, also known as total esophagogastrectomy or transthoracic esophagectomy, is a procedure that has been proposed to eliminate symptoms of refractory GERD. It involves transecting the esophagus from the stomach and creating an esophagojejunal anastomosis. The biliopancreatic limb is then anastomosed to the jejunal loop distal to the esophagojejunal anastomosis to drain the gastric contents.³⁹ (Refer to Coverage Limitations section)

• Transoral radiofrequency therapy (eg, Stretta System) is an endoscopic procedure that reportedly delivers radiofrequency (RF) energy via a single-use catheter to deliver constant tissue temperature for collagen contraction, purportedly resulting in tissue shrinkage and tightening of the gastroesophageal junction. (Refer to Coverage Limitations section)

For information regarding surgical treatment for obesity, please refer to Bariatric Surgery Medical Coverage Policy.

For information regarding treatment of hiatal hernia, please refer to Laparoscopic Hiatal Hernia Repair Medical Coverage Policy.

Achalasia and Gastroesophageal Reflux Disease Treatments Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0335-023
Page: 6 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Determination

Please refer to the member's applicable pharmacy benefit to determine benefit availability and the terms and conditions of coverage for medication for the treatment of achalasia and GERD.

Achalasia

Humana members may be eligible under the Plan for the following surgical treatments for achalasia:

• Myotomy (achalasia type I – III); OR
• Pneumatic balloon dilation (achalasia type I – III); OR
• POEM (achalasia type III only);

AND when all the following criteria are met:

• 18 years of age or older; AND
• Diagnosis confirmed by esophageal motility testing

GERD

Humana members may be eligible under the Plan for the following fundoplication procedures for GERD:

• Dor fundoplication; OR
• Nissen fundoplication; OR
• Toupet fundoplication

AND when all the following criteria are met:

• Esophagogastroduodenoscopy (EGD) to rule out non-GERD etiology; AND
• Failure of standard dosing of proton pump inhibitor (PPI) treatment (eg, Dexilant [dexlansoprazole]) for 2 consecutive months or greater

Humana members may be eligible under the Plan for revision of a fundoplication for the following indications:

• Dysphagia; OR
• Persistent or recurrent symptoms of reflux (eg, heartburn)

For information regarding EGD, please refer to Diagnostic Esophagogastroduodenoscopy or Esophagoscopy (59 years of age or younger) Medical Coverage Policy.

Coverage Limitations

Humana members may NOT be eligible under the Plan for the surgical treatment of achalasia or GERD for any indications other than those listed above including, but may not be limited to:

• Electrical stimulation of the lower esophageal sphincter (eg, EndoStim); OR
• Endoscopic plication or suturing (eg, Medigus ultrasonic surgical endostapler [MUSE] transoral incisionless esophagogastric fundoplication [EsophyX, EsophyX Z]); OR
• Laparoscopic adjustable gastric banding (eg, LAP-BAND, Realize); OR
• Magnetic esophageal sphincter augmentation (eg, LINX Reflux Management System); OR
• Peroral endoscopic myotomy (POEM) for type I or II achalasia; OR
• Roux-en-Y gastric bypass (RYGBP) (open or laparoscopic); OR
• Total esophagogastric disconnection (TED); OR
• Transoral thermal (eg, radiofrequency) therapy to LES and/or gastric cardia (eg, Stretta System)

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Achalasia and Gastroesophageal Reflux Disease Treatments Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0335-023
Page: 8 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Humana members may NOT be eligible under the Plan for any fundoplication procedure other than those listed above in the Coverage Determination section including, but may not be limited to:

• 90° APF; OR
• Hill repair; OR
• Lind partial fundoplication²⁸

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Note: The criteria for implantation of anti-gastroesophageal reflux device (eg, magnetic sphincter augmentation [LINX]) are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Additional information about achalasia and GERD may be found from the following websites:

Background

• American College of Gastroenterology
• American Gastroenterological Association
• National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

Provider Claims Codes

Achalasia and Gastroesophageal Reflux Disease Treatments Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0335-023
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CPT® Code(s)

• 32665
• 43210
• 43214
• 43233
• 43253
• 43257
• 43279
• 43280
• 43284
• 43285
• 43325
• 43327
• 43328

Achalasia and Gastroesophageal Reflux Disease Treatments Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0335-023
Page: 10 of 18

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• 43330 Esophagomyotomy (Heller type); abdominal approach
• 43331 Esophagomyotomy (Heller type); thoracic approach
• 43497 Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM])
• 43499 Unlisted procedure, esophagus
• 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less)
• 43659 Unlisted laparoscopy procedure, stomach
• 43770

• 43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components)

Not Covered if used to report any treatment outlined in Coverage Limitations section

• 43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy

Not Covered if used to report any treatment outlined in Coverage Limitations section

• 43999 Unlisted procedure, stomach

Not Covered if used to report any treatment outlined in Coverage Limitations section

CPT® category III

No code(s) identified

HCPCS Code(s)

A9999 Miscellaneous DME supply or accessory, not otherwise specified

Not Covered if used to report any treatment outlined in Coverage Limitations section

References

1. Agency for Healthcare Research and Quality (AHRQ). Comparative Effectiveness Review. Comparative effectiveness of management strategies for gastroesophageal reflux disease: update. https://www.ahrq.gov. Published September 2011. Accessed April 11, 2023.
2. American Academy of Pediatrics (AAP). Clinical Report. Diagnosis and management of gastroesophageal reflux in preterm infants. https://www.aap.org. Published July 2018. Accessed April 17, 2023.
3. American College of Gastroenterology (ACG). Guideline. Diagnosis and management of achalasia. https://www.gi.org. Published September 2020. Accessed April 13, 2023.
4. American College of Gastroenterology (ACG). Guideline. Diagnosis and management of gastroesophageal reflux disease. https://www.gi.org. Published November 22, 2021. Accessed April 13, 2023.
5. American Gastroenterological Association (AGA). AGA clinical practice update on the personalized approach to the evaluation and management of GERD: expert review. https://www.gastro.org. Published May 2022. Accessed April 13, 2023.
6. American Gastroenterological Association (AGA). American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease. https://www.gastro.org. Published October 2008. Accessed April 13, 2023.
7. American Gastroenterological Association (AGA). Clinical practice update: the use of per-oral endoscopic myotomy in achalasia: expert review and best practice advice for the AGA institute. https://www.gastro.org. Published November 2017. Accessed April 13, 2023.
8. American Society for Gastrointestinal Endoscopy (ASGE). ASGE guideline on the management of achalasia. https://www.asge.org. Published 2020. Accessed April 13, 2023.
9. American Society for Gastrointestinal Endoscopy (ASGE). Guideline. The role of endoscopy in the evaluation and management of dysphagia. https://www.asge.org. Published 2014. Accessed April 13, 2023.

9. American Society for Gastrointestinal Endoscopy (ASGE). Guideline. The role of endoscopy in the management of GERD. https://www.asge.org. Published 2015. Accessed April 13, 2023.
10. American Society of General Surgeons (ASGS). LINX statement of support from ASGS. https://theasgs.org. Published 2014. Accessed April 17, 2023.
11. American Society of General Surgeons (ASGS). Position Statement. Natural orifice surgery and transoral incisionless fundoplication. https://theasgs.org. Published 2009. Accessed April 17, 2023.
12. American Society of General Surgeons (ASGS). Position Statement. Transoral fundoplication. https://theasgs.org. Published 2011. Accessed April 17, 2023.
13. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). Implantation of anti-gastroesophageal reflux device (100.9). https://www.cms.gov. Published January 1, 2021. Accessed April 24, 2023.
14. ClinicalKey. Ferri, F. Achalasia. In: Ferri, F. Ferri’s Clinical Advisor 2023. Elsevier; 2023:14-16.e2. https://www.clinicalkey.com Accessed April 11, 2023.
15. ClinicalKey. Ferri, F. Gastroesophageal reflux disease (GERD). In: Ferri, F. Ferri’s Clinical Advisor 2023. Elsevier; 2023:656-657.e2. https://www.clinicalkey.com Accessed April 11, 2023.
16. ClinicalKey. Kavitt R, Vaezi M. Diseases of the esophagus. In: Flint P, Haughey B, Lesperance M, et al. Cummings Otolaryngology: Head and Neck Surgery. 7th ed. Elsevier; 2021:964-991.e3. https://www.clinicalkey.com Accessed April 11, 2023.

Achalasia and Gastroesophageal Reflux Disease Treatments Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0335-023
Page: 13 of 18
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18. ECRI Institute. Clinical Evidence Assessment. EsophyX (EndoGastric Solutions, Inc.) for treating gastroesophageal reflux disease. https://www.ecri.org. Published February 18, 2016. Updated May 9, 2023. Accessed May 11, 2023.
19. ECRI Institute. Clinical Evidence Assessment. LINX reflux management system (Ethicon US, LLC) for treating gastroesophageal reflux disease. https://www.ecri.org. Published February 1, 2018. Updated May 2023. Accessed May 18, 2023.
20. Hayes, Inc. Clinical Research Response (ARCHIVED). EsophyX device (Endogastric Solutions) versus LINX reflux management system (Ethicon) (product comparison). https://evidence.hayesinc.com. Published June 25, 2021. Accessed April 10, 2023.
21. Hayes, Inc. Emerging Technology Report (ARCHIVED). EndoStim lower esophageal sphincter stimulation system. https://evidence.hayesinc.com. Published May 8, 2020. Accessed April 24, 2023.
22. Hayes, Inc. Evidence Analysis Research Brief. Laparoscopic surgery for gastroesophageal reflux disease refractory to medical therapy. https://evidence.hayesinc.com. Published April 21, 2023. Accessed April 24, 2023.
23. Hayes, Inc. Health Technology Assessment. Magnetic sphincter augmentation with LINX reflux management system (Ethicon Inc.) for treatment of gastroesophageal reflux disease. https://evidence.hayesinc.com. Published August 26, 2022. Accessed April 7, 2023.
24. Hayes, Inc. Health Technology Assessment. Peroral endoscopic myotomy for treatment of esophageal achalasia. https://evidence.hayesinc.com. Published December 3, 2019. Updated March 7, 2023. Accessed April 10, 2023.
25. Hayes, Inc. Health Technology Assessment. Stretta (Respiratory Technology Corp.) radiofrequency treatment for gastroesophageal reflux disease. https://evidence.hayesinc.com. Published August 26, 2022. Accessed April 7, 2023.

Achalasia and Gastroesophageal Reflux Disease Treatments Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0335-023
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26. Hayes, Inc. Health Technology Assessment. Transoral incisionless fundoplication 2.0 with EsophX (EndoGastric Solutions, Inc.) for treatment of gastroesophageal reflux. https://evidence.hayesinc.com. Published May 9, 2023. Accessed May 11, 2023.
27. Hayes, Inc. Health Technology Assessment (ARCHIVED). Comparative effectiveness review of endoscopic therapy for gastroesophageal reflux disease. https://evidence.hayesinc.com. Published October 7, 2017. Updated January 24, 2022. Accessed April 10, 2023.
28. Hayes, Inc. Medical Technology Directory. Laparoscopic surgery for gastroesophageal reflux disease refractory to medical therapy. https://evidence.hayesinc.com. Published April 26, 2018. Updated April 6, 2022. Accessed April 10, 2023.
29. MCG Health. Fundoplication and hiatal hernia repair, abdominal. 26th edition. https://www.mcg.com. Accessed April 5, 2023.
30. MCG Health. Fundoplication and hiatal hernia repair, by laparoscopy. 26th edition. https://www.mcg.com. Accessed April 11, 2023.
31. MCG Health. Fundoplication and hiatal hernia repair, transthoracic. 26th edition. https://www.mcg.com. Accessed April 5, 2023.
32. MCG Health. Implantable magnetic esophageal ring (Linx). 26th edition. https://www.mcg.com. Accessed April 5, 2023.
33. MCG Health. Myotomy, lower esophageal sphincter: open or laparoscopic. 26th edition. https://www.mcg.com. Accessed April 5, 2023.
34. MCG Health. Radiofrequency energy delivery to gastroesophageal junction (Stretta). 26th edition. https://www.mcg.com. Accessed April 5, 2023.

Achalasia and Gastroesophageal Reflux Disease Treatments Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0335-023
Page: 15 of 18

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

35. MCG Health. Transoral (endoluminal) gastroplication or suturing. 26th edition. https://www.mcg.com. Accessed April 5, 2023.
36. Merck Manual: Professional Version. Achalasia.https://www.merckmanuals.com. Updated September 2022. Accessed April 11, 2023.
37. Merck Manual: Professional Version. Gastroesophageal reflux disease (GERD). https://www.merckmanuals.com. Updated September 2022. Accessed April 11, 2023.
38. Merck Manual: Professional Version. Gastroesophageal reflux in infants. https://www.merckmanuals.com. Updated September 2022. Accessed April 11, 2023.
39. North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHN). Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition. https://www.naspghan.org. Published March 2018. Accessed April 13, 2023.
40. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Clinical spotlight review: endoluminal treatments for gastroesophageal reflux disease. https://www.sages.org. Published March 2017. Accessed April 17, 2023.
41. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for the surgical treatment of esophageal achalasia. https://www.sages.org. Published May 2011. Accessed April 17, 2023.
42. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for the surgical treatment of gastroesophageal reflux disease (GERD). https://www.sages.org. Published April 2021. Accessed April 17, 2023.
43. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).

• Guidelines for the use of peroral endoscopic myotomy (POEM) for the treatment of achalasia. https://www.sages.org. Published July 2020. Accessed April 17, 2023.
• Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD). https://www.sages.org. Published 2022. Accessed April 17, 2023.
• Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Position statement on endoluminal therapies for gastrointestinal disease. https://www.sages.org. Published November 2009. Accessed April 17, 2023.
• UpToDate, Inc. Approach to refractory gastroesophageal reflux disease in adults. https://www.uptodate.com. Updated March 2023. Accessed April 10, 2023.
• UpToDate, Inc. Gastroesophageal reflux in infants. https://www.uptodate.com. Updated March 2023. Accessed April 10, 2023.
• UpToDate, Inc. Magnetic sphincter augmentation (MSA). https://www.uptodate.com. Updated March 2023. Accessed April 10, 2023.
• UpToDate, Inc. Management of gastroesophageal reflux disease in children and adolescents. https://www.uptodate.com. Updated March 2023. Accessed April 10, 2023.
• UpToDate, Inc. Non-acid reflux: clinical manifestations, diagnosis and management. https://www.uptodate.com. Updated March 20, 2023. Accessed April 10, 2023.
• UpToDate, Inc. Overview of the treatment of achalasia. https://www.uptodate.com. Updated March 2023. Accessed April 10, 2023.
• UpToDate, Inc. Peroral endoscopic myotomy (POEM).https://www.uptodate.com. Updated March 2023. Accessed April 10, 2023.
• UpToDate, Inc. Radiofrequency treatment for gastroesophageal reflux disease. https://www.uptodate.com. Updated March 2023. Accessed April 10, 2023.
• UpToDate, Inc. Surgical management of gastroesophageal reflux in adults. https://www.uptodate.com. Updated March 2023. Accessed April 10, 2023.
• UpToDate, Inc. Surgical myotomy for achalasia. https://www.uptodate.com. Updated March 2023. Accessed April 10, 2023.
• US Food & Drug Administration (FDA). 510(k) summary: EndoGastric Solutions EsophyX2 system. https://www.fda.gov. Published November 6, 2009. Accessed April 22, 2015.
• US Food & Drug Administration (FDA). 510(k) summary: EsophyXZ. https://www.fda.gov. Published May 1, 2016. Accessed May 2, 2017.
• US Food & Drug Administration (FDA). 510(k) summary: Medigus SRS endoscopic stapling system. https://www.fda.gov. Published March 19, 2014. Accessed April 22, 2015.
• US Food & Drug Administration (FDA). 510(k) summary: MUSE system. https://www.fda.gov. Published January 20, 2015. Accessed April 29, 2015.
• US Food & Drug Administration (FDA). 510(k) summary: OverStitch endoscopic suturing system. https://www.fda.gov. Published August 29, 2019. Accessed April 23, 2020.
• US Food & Drug Administration (FDA). 510(k) summary: Stretta system. https://www.fda.gov. Published January 27, 2000. Accessed April 27, 2015.

Achalasia and Gastroesophageal Reflux Disease Treatments Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0335-023
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Summary of safety and effectiveness data (device modification): LINX reflux management system.

https://www.fda.gov. Published March 22, 2012. Accessed April 22, 2015.

Achalasia and Gastroesophageal Reflux Disease Treatments Effective Date: 05/25/2023
Revision Date: 05/25/2023
Review Date: 05/25/2023
Policy Number: HUM-0335-023
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Appendix A

Achalasia Types