54 Guidelines for Coverage of Laparoscopically Implanted Magnetic Esophageal Ring The guidelines set forth below provide an overview of the requirements for Medically Necessary treatment of GERD using a laparoscopically implanted magnetic esophageal ring. These guidelines are subject to periodic change without notice, and prior authorization should be obtained through Quantum Health well in advance when this treatment option is being considered. • The individual has been diagnosed with severe GERD, as documented by endoscopy. If endoscopy is normal, objective evidence of reflux should include at least one of the following: • 24-hour ambulatory esophageal pH monitoring; or • Barium swallow study; and • The individual continues to have chronic GERD symptoms that have been resistant to conservative medical treatment and unresponsive to two or more of the following lifestyle modifications: • Weight loss for overweight or obese patients; or • Avoidance of late meals and/or specific foods that cause heartburn (spicy foods, citrus, fatty foods, chocolate, caffeine, carbonated drinks, alcohol, etc.); or • Elevation of the head of the bed for patients who develop heartburn or regurgitation when lying down; or • Avoidance of recumbent position within 2-3 hours after a meal; and • Laparoscopic implantation of a magnetic esophageal ring is intended solely as a minimally invasive alternative to surgical treatment. • The individual does not have evidence of: • Barrett’s Esophagus • Esophageal cancer • Motility and/or swallowing issues • Previous bariatric or esophageal surgery • Morbid obesity with a body mass index > 35 kg/m2 at the time of surgery • Significant hiatal hernia > 3 cm as defined by manometry, upper GI (barium swallow), or endoscopy (one of these measurements should be 3-cm or less) • Allergy to titanium, stainless steel, nickel or iron materials; and Coverage is available for the implantation, replacement, and/or removal of the device, and for the device itself, when the above criteria are met. Coverage Information Charges for treatment of GERD with a laparoscopically implanted magnetic esophageal ring are subject to all limitations as set forth in the Schedule of Benefits and the section on Covered Charge Limits. • Coverage for these services is limited to in-network benefits only. • There is no out-of-network coverage for implantation/removal of a laparoscopically implanted magnetic esophageal ring or for the device itself.