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MP 7.01.02 Angelchik™ Anti-Reflux Prosthesis (Archived)

Medical Policy
Section
Surgery
 
Original Policy Date
12/1/95
Last Review Status/Date
Archived/9:2009
Issue
3:2003
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


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.


Policy Guidelines

No applicable information


Benefit Application

BlueCard/National Account Issues

Some state or federal mandates (i.e., the FEP) prohibit plans from denying FDA-approved technologies as investigational. In these instances plans may have to consider the coverage eligibility of FDA-approved technologies on the basis of medical necessity alone.


Rationale

2003 Update
 
A review of the peer-reviewed literature on Medline from the period of 2002 through June 2003 found one article on the Angelchik prosthesis. Varshney and colleagues reported on the follow-up assessment of patients with the Angelchik prosthesis and found poor long-term results. (1) Of the 65 patients evaluated, 10 patients required removal of the device and only 66% achieved effectiveness in symptomatic assessment. Frequent complications, such as dysphagia and distal slippage and proximal migration of the prosthesis were also noted. It also appears this device is no longer being marketed by the manufacturer.

References:

  1. Varshney S, Kelly JJ, Branagan G et al. Angelchik prosthesis revisited. World J Surg 2002; 26(1):129-33.

 

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 

Type of Service 

Surgery 

Place of Service 

Inpatient 


Index

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


Policy History

Date Action Reason
12/1/95 Add to Surgery section New policy
7/12/02 Replace Policy Policy reviewed without literature review; new review date only
10/9/03 Replace Policy Literature review update; no further review scheduled.
09/2009 Policy Archived  


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