Anthem Blue Cross Connecticut CG-SURG-92 Paraesophageal Hernia Repair Form

This document addresses paraesophageal hernia (PEH) repair. This document does not address sliding hiatal hernia repair or surgical procedures for the treatment of Barrett’s Esophagus.

Note: For additional information, please see:

• CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
• CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus
• SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
• SURG.00131 Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)

Clinical Indications

Medically Necessary:

1. Paraesophageal hernia repair is considered medically necessary for symptomatic individuals with all of the following indications:
   1. A paraesophageal hernia is demonstrated on diagnostic imaging or endoscopic study; and
   2. One of the following conditions exists:
      1. Gastric outlet obstruction caused by the hernia; or
      2. Persistent anemia without other identified causes after evaluation; or
      3. Suspected or documented gastric strangulation; or
      4. Gastroesophageal reflux symptoms unresponsive to medical treatment.
2. Paraesophageal hernia repair during a gastric surgical procedure, including but not limited to bariatric surgery, is considered medically necessary when a paraesophageal hernia has been detected.
3. Recurrent paraesophageal hernia repair is considered medically necessary when all of the criteria below are met:
   1. A paraesophageal hernia is demonstrated on diagnostic imaging or endoscopic study performed after the previous repair; and
   2. A condition listed in criterion A persists or recurs:
      1. Gastric outlet obstruction caused by the hernia; or
      2. Persistent anemia without other identified cause after evaluation; or
      3. Suspected or documented gastric strangulation; or
      4. Gastroesophageal reflux symptoms unresponsive to medical treatment.

Not Medically Necessary:

Paraesophageal hernia repair is considered not medically necessary when the criteria above are not met and for all other indications, including but not limited to asymptomatic individuals not undergoing gastric surgery or during surgery for other than gastric indications.