53 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. • Coverage is available only for use of a laparoscopically implanted magnetic esophageal ring where it is medically appropriate as outlined above.