In article
Post by c***@intel.comI would like to know your opinion about a new procedure by the name of
Esophyx. I've read that they are now doing this procedure in the
U.S. I would like to know how you think this compares with the
Plicator procedure and if you think the Esophyx procedure has the
potential to become the preferred treatment for GERD.
Thanks,
Christine
SAGES= Society of American Gastrointestinal Endoscopic Surgeons ... the
leading group of physicians representing current surgical practice.
CPT= Current Procedural Terminology ... a list of procedure codes that
surgeons submit to insurance companies to provide a more-or-less
standardized reimbursement schedule
I was just invited to a meeting at this year's SAGES meeting coming up
in June in Philadelphia there will be a meeting whose purpose is to
develop a position statement that will represent SAGES' position on this
type of endoluminal treatment for GERD. Currently, insurance compananies
won't pay for any such treatment. In fact, there isn't even a CPT code
for it. That means that any time a surgeon does Esophyx or Plicator, he
she must submit the generic CPT code for "unlisted procedure". This
gaurantees scrutiny by the insurance company, and likewise is virtually
certain to result in a denial of precertification. Even with a CPT code
specific to Esophyx or Plicator, it's likely the procedure will still be
labeled "investigational" and most insurance companies won't cover it,
but without SAGES' endorsement, neither procedure has a prayer of EVER
remaining viable.
So, first, the two mfgrs need to get a CPT code approved specific to
endoluminal GERD treatment. Currently, there is a CPT code 43324 (same
code that is used for Nissen Fundoplication) that represents:
"CPT 43324
The physician mobilizes the lower end of the esophagus and folds the
fundus of the stomach around it. The physician accesses the lower
esophagus through an upper abdominal incision. The fundus of the
stomach is moved up and wrapped around the terminal 3 cm to 4 cm of the
esophagus and sutured into place. The lower esophageal sphincter passes
through a short tunnel of stomach muscle, which prevents reflux through
the sphincter. When performed for hiatal hernia, this procedure may
include a sutured tightening of the junction of the diaphragmatic crura
behind the esophagus."
Endogastric Solutions, (mfgr of Esophyx) wants SAGES to endorse changing
that code my removing the line "The physician accesses the lower
esophagus through an upper abdominal incision." That way, Esophyx will
be equated to Nissen, on paper at least. Insurance companies will still
likely deny Esophyx for the time being, but this is a necessary first
step. The other thing Endogastric Solutions wants SAGES to do at this
meeting is actually endorse Esophyx as a primary treatment and support
their bid for legitimacy with the insurance companies. I don't see
Endogastric Solutions on the list of supporters/donors for this year's
meeting, for those of you who might be conspiracy theorists.
Lot's of politics here. The insurance companies don't want to pay for
new treatments. They know that if they make it easier for people to have
surgery for GERD then more people will have that surgery and it will
cost them more money than they pay out now. Endogastric Solutions knows
that if they don't get a CPT code, and if they don't get the insurance
companies to move Esophyx out of the "investigational" category, they'll
go out of business, so we also have Endogastric Solutions running around
behind the scenes lobbying for acceptance of their new and uproven
procedure. And we have a bunch of endoscopic surgeons in the middle, who
aren't sure if this is a valid treatment or not because there is
insufficient data to draw a definitive conclusion.
Anyway...a glimpse into contemporary medical politics.
HMc