Newly Issued Technology Coverage Statement on Minimally Invasive Surgical Options for GERD
REDMOND, Washington. – EndoGastric Solutions® (EGS), a leader in incisionless procedural therapy for gastroesophageal reflux disease (GERD), announced today that Health Care Service Corporation (HCSC), a top commercial health insurer in the U.S, has issued a medical coverage policy for Transoral Incisionless Fundoplication (TIF®) procedures effective July 15, 2016.
HCSC will make the TIF procedure with EsophyX® device available to its approximately 15 million members in the treatment of chronic reflux. HCSC network includes its affiliates Blue Cross Blue Shield of Illinois, Blue Cross Blue Shield of Montana, Blue Cross Blue Shield of New Mexico, Blue Cross Blue Shield of Oklahoma and Blue Cross Blue Shield of Texas.
HCSC’s coverage policy was based on multiple peer-reviewed, randomized controlled trial evidence, including sham-control groups and long-term outcome data, consistently demonstrating that the TIF procedure is a safe, effective and durable treatment option for GERD.
Advocacy for this policy included a joint recommendation from the American Gastroenterological Association (AGA) and The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).
“On behalf of GERD sufferers, I would like to express our deep appreciation to HCSC for being the first major commercial carrier to give their patients access to our TIF procedure,” said Skip Baldino, President and CEO of EndoGastric Solutions. “We are grateful to the leading GI and surgical societies for the tangible actions to support their members’ ability to offer a well-tested and proven therapeutic intervention to their patients needing anatomical correction to control GERD symptoms.”
This positive coverage decision expands on the American Medical Association’s decision to create a new Category 1 Current Procedural Terminology (CPT®) Code 43210: EGD Esophagogastric Fundoplasty, which became effective in January 2016.
“CPT code 43210 was assigned a zero-day global period which means that follow-up visits are billed separately,” said Philip Macdonald, Vice President, Healthcare Economics, Policy & Reimbursement. “This is a unique situation for a foregut surgery; typically, surgical procedures are reimbursed with a payment covering care from procedure day plus up to 90 days after. Patients are now able to follow-up with the healthcare team members that have been most involved in their wellness management.”
To date, EGS has achieved other key reimbursement milestones. Cahaba Government Benefit Administrators,® LLC (Cahaba GBA), a Medicare Administrative Contractor (MAC), approved reimbursement of the TIF procedure (since May 2015). Cahaba GBA administers benefit claims in Alabama, Georgia and Tennessee for over three million members.
The TIF procedure with EsophyX device is also covered by Novitas Solutions, a separate Medicare Administrative Contractor, which covers over nine million members in Arkansas, Colorado, Louisiana Mississippi, New Mexico, Oklahoma and Texas (since August 2012), and Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania (since April 2013).
About Current Procedural Terminology (CPT®)
CPT codes are a listing of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians and other healthcare providers, patients and third parties. CPT® is registered trademark of the American Medical Association.
The Federal Register has posted coding and payment information specific to the new CPT code, allowing patients to more easily receive access to treatment for GERD. Physicians and hospitals can reference CPT Code 43210 EGD esophagogastric fundoplasty and APC 5331 Complex GI Procedures for TIF procedures as of January 1, 2016.