BlueCross and BlueShield of Montana Medical Policy/Codes
Angelchik Anti-Reflux Prosthesis
Chapter: Surgery: Procedures
Current Effective Date: August 27, 2013
Original Effective Date: August 27, 2013
Publish Date: May 27, 2013
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

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Blue Cross and Blue Shield of Montana (BCBSMT) considers the Angelchik™ anti-reflux prosthesis experimental, investigational and unproven.

Rationale

A review of the peer-reviewed literature on Medline from the period of 2002 through January 2008 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. 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.

Coding

Disclaimer for coding information on Medical Policies

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.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes
53.7, 530.11, 530.81, 553.3
Procedural Codes: L8499
References
  1. Angelchik™ Antireflux Prosthesis.  American Medical Association Diagnostic and Therapeutic Technology Assessment, (1985 October 31) 1-6.
  2. Angelchik™ Anti-Reflex Prosthesis.  Chicago, Illinois: Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (1986 July) Evaluation, No. 17, pages 17 - 25.
  3. Evans, D.F., Robertson, C.S., et al.  An objective long-term evaluation of the Angelchik™ antireflux prosthesis.  Annals of the Royal College of Surgeons of England (1991) 73(6): 355-360.
  4. Maddern, G.J., Myers, J.C., et al.  The effect of the Angelchik™ prosthesis in esophageal and gastric function.  Archives of Surgery (1991) 126(11): 1418-1422.
  5. Jakaite, D., Gourley, G.R., et al.  The effect of the Angelchik™ prosthesis in pediatric-sized developmentally disabled patients.  Journal of Pediatric Gastroenterology and Nutrition (1991) 13(2): 186-191.
  6. Kmiot, W.A., Kirby, R.M., et al. Prospective randomized trial of Nissen fundoplication and Angelchik™ prosthesis in the surgical treatment of medically refractory gastro-esophageal reflux disease.  British Journal of Surgery (1991) 78(10): 1181-1184.
  7. Fornaro, R., Ferraris, R., et al.  The Angelchik™ prosthesis in the surgical therapy of reflux esophagitis.  Short and long term results.  Acta Chirurgica Belgica (1993) 93(4): 135-139.
  8. Thibault, C., Marceau, P., et al.  The Angelchik™ prosthesis:  Long-term clinical and technical follow-up.  Canadian Journal of Surgery (1994) 37(1): 12-17. 
  9. Maxwell-Armstrong, C.A., Steele, R.J., et al.  Long-term results of the Angelchik™ prosthesis for gastroesophageal reflux.  British Journal of Surgery (1997) 84(6): 862-864.
  10. Varshney, S., Kelly, J.J., et al.  Angelchik™ prosthesis revisited.  World Journal of Surgery (2002) 26(1): 129-33.
  11. Angelchik™ Anti-Reflux Prosthesis. Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 October) Surgery 7.01.02.
History
May 2013  New 2013 BCBSMT medical policy.  Considered experimental, investigational and unproven. 
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Angelchik Anti-Reflux Prosthesis