CAM 70102

Angelchik™ Anti-Reflux Prosthesis

Category:Surgery   Last Reviewed:December 2020
Department(s):Medical Affairs   Next Review:December 2999
Original Date:December 1995    

Description:
The Angelchik anti-reflux prosthesis is designed to reduce and prevent further sliding of a hiatal hernia and prevent reflux of gastric contents into the esophagus. The device is a C-shaped elastomer ring, filled with silicone gel, and surrounded by a radiopaque tie. The prosthesis is surgically implanted below the diaphragm and encircles the lower esophageal segment. It is intended as an alternative to traditional gastropexy or fundoplication procedures.


Policy:
The Angelchik anti-reflux prosthesis is considered INVESTIGATIONAL.

References:

  1. Varshney S, Kelly JJ, Branagan G et al. Angelchik prosthesis revisited. World J Surg 2002; 26(1):129-33.
  2. Medical Services Advisory Committee (MSAC). Endoluminal gastroplication for gastro-oesophageal reflux disease.  Assessment report.  MSAC Application 1047.  Canberra, Austrialia: MSAC; 2002. 
  3. National Institute for Clinical Excellence (NICE).  Endoscopic injection of bulking agents for gastro-oesophageal reflux disease.  Interventional Procedure Guidance 55.  London, UK: NICE; April 2004. 
  4. JAMA & ARCHIVES, Archives of Surgery.  The Effect of the Angelchik Prosthesis on Esophageal and Gastric Function.  Vol. 126 No.11, November 1991. 

Coding Section

Codes Number Description
CPT 43499 Unlisted procedure, esophagus
ICD-9 Procedure   53.7 Repair of diaphragmatic hernia, abdominal approach
ICD-9 Diagnosis  530.11 Reflux esophagitis
   530.81 Esophageal reflux/gastroesophageal reflux 
   553.3 Diaphragmatic hernia 
HCPCS L8499 Unlisted procedure for miscellaneous prosthetic services   
ICD-10-CM (effective 10/01/15)  K210  Gastro-esophageal reflux disease with esophagitis 
  K219  Gastro-esophageal reflux disease without esophagitis 
  K449  Diaphragmatic hernia without obstruction or gangrene 
ICD-10-PCS (effective 10/01/15)  0BQR4ZZ Repair Right Diaphragm, Percutaneous Endoscopic Approach 
  0BQS4ZZ  Repair Left Diaphragm, Percutaneous Endoscopic Approach 
  0BUR47Z  Supplement Right Diaphragm with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 
  0BUR4JZ  Supplement Right Diaphragm with Synthetic Substitute, Percutaneous Endoscopic Approach 
  0BUR4KZ  Supplement Right Diaphragm with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 
  0BUS47Z  Supplement Left Diaphragm with Autologous Tissue Substitute, Percutaneous Endoscopic Approach 
  0BUS4JZ  Supplement Left Diaphragm with Synthetic Substitute, Percutaneous Endoscopic Approach 
  0BUS4KZ  Supplement Left Diaphragm with Nonautologous Tissue Substitute, Percutaneous Endoscopic Approach 
Type of Service Surgery  
Place of Service Inpatient         

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

Index
Angelchik anti-reflux prosthesis
Anti-reflux prosthesis, Angelchik
Prosthesis, anti-reflux

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2013 Forward     

12/17/2020 

Annual review, no change to policy intent. 

12/12/2019

Annual review, no change to policy intent. 

12/21/2018 

Annual review, no change to policy intent. 

12/20/2017 

Annual review, no change to policy intent. 

12/27/2016 

Annual review, no change to policy intent. 

09/22/2015 

Added ICD-10 codes to policy. 

12/01/2014 

Annual review, no change to policy intent. Added coding.

12/9/2013

Annual Review. No changes made.


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