Humana Laparoscopic Hiatal Hernia Repair Form

Description

Hiatal hernias occur when the fundus (upper part of the stomach) bulges through the esophageal hiatus in the diaphragm (the opening where the esophagus passes from the thoracic to the abdominal cavity). Sliding hernias (type I) are the most common type and are generally asymptomatic. There are four main classifications of hiatal hernias.

Types II-IV

These are known as paraesophageal hiatal hernias. In these types of hernias, the fundus pushes up through the esophageal hiatus. Paraesophageal hiatal hernia surgery includes positioning the stomach back into the abdominal cavity and closing the diaphragmatic defect with sutures. Mesh may be used to reinforce the area. In addition, fundoplication is typically performed with paraesophageal hiatal hernia repair to reduce the risk of postoperative gastrointestinal reflux and to reinforce the repair to prevent recurrence.

Fundoplication

Is a surgical procedure in which the fundus is wrapped around the lower end of the esophagus.

• Nissen fundoplication is the most used type of fundoplication in which the fundus of the stomach is wrapped completely around the lower end of the esophagus, reinforcing the lower esophageal sphincter (LES) with the goal of reducing the amount of stomach acid that may back up into the esophagus.
• Partial fundoplication is created by the fundus partially enveloping the distal esophagus and designed to allow a reduction in postoperative dysphagia.

Types of partial fundoplication procedures include, but may not be limited to:

1. 90° anterior partial fundoplication (APF) is a limited fundoplication procedure in which sutures are placed between the distal esophagus and the posterior hiatal pillar, which reportedly changes the angle of His (also known as the esophagogastric angle). Sutures are also used to anchor the gastric fundus to the anterior esophagus and the fundal fold to the anterior esophagus. (Refer to Coverage Limitations section)
2. Dor fundoplication is a procedure in which the fundus is partially wrapped around the distal esophagus and sutured to create a low-pressure valve. This is performed anteriorly and usually in an individual who also requires a Heller myotomy.
3. Hill repair attempts to change the antireflux barrier by reportedly reducing the hernia and anchoring the gastroesophageal junction by the normal attachment to the pre-aortic fascia recreating the gastroesophageal valve. (Refer to Coverage Limitations section)
4. Lind partial fundoplication is performed by suturing the fundus to the esophagus at the left and right lateral positions as well as anteriorly on the left position. (Refer to Coverage Limitations section)
5. Toupet fundoplication is similar to the Nissen fundoplication; however, this procedure utilizes a 270° wrap of the stomach around the lower esophagus rather than 360° that is used in the Nissen procedure. This may reduce the amount of pressure or compression that is placed on the lower esophagus.

Laparoscopic Hiatal Hernia Repair Effective Date: 06/22/2023 Revision Date: 06/22/2023 Review Date: 06/22/2023 Policy Number: HUM-0599-002

Humana's documents are updated regularly online.

When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing. Compared to the Nissen fundoplication, which may help an individual with impaired esophageal motility. For information regarding gastroesophageal reflux disease procedures, please refer to Achalasia and Gastroesophageal Reflux Disease Treatments Medical Coverage Policy. For information regarding mesh products, please refer to Skin and Tissue Substitutes Medical Coverage Policy. For information regarding coverage determination/limitations for bariatric surgery please refer to Bariatric Surgery Medical Coverage Policy.

Coverage Determination

The scope of this policy is limited to laparoscopic hiatal hernia repair. Open surgical approaches to hiatal hernia repair are not subject to the criteria within this medical coverage policy.

Humana members may be eligible under the Plan for laparoscopic hiatal hernia repair with or without fundoplication procedure (DOR, Nissen or Toupet fundoplication) and/or mesh placement when the following criteria are met:

• Paraesophageal hiatal hernia (type II-IV) demonstrated by diagnostic imaging or upper endoscopy; AND any of the following:
• Acute gastric volvulus; OR
• Gastric obstruction; OR
• Gastric strangulation; OR
• Gastroesophageal reflux symptoms unresponsive to proton pump inhibitor (PPI) treatment for 3 consecutive months or greater under the direction of a healthcare professional; OR
• Persistent anemia when other causes have been ruled out

Humana members may be eligible under the Plan for paraesophageal hiatal hernia repair, if detected, during a medically necessary bariatric surgery.

Humana members may be eligible under the Plan for revision laparoscopic hiatal hernia repair when the following criteria are met:

• Recurrence of paraesophageal hiatal hernia (type II-IV) demonstrated by diagnostic imaging or upper endoscopy; AND any of the following:
• Acute gastric volvulus; OR
• Gastric obstruction; OR
• Gastric strangulation; OR
• Gastroesophageal reflux symptoms unresponsive to proton pump inhibitor (PPI) treatment for 3 consecutive months or greater under the direction of a healthcare professional; OR
• Persistent anemia when other causes have been ruled out

Coverage Limitations

Humana members may NOT be eligible under the Plan for laparoscopic hiatal hernia repair for any indications other than those listed above including, but may not be limited to, asymptomatic hiatal hernia. All other indications are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for any fundoplication procedure other than those listed above including, but may not be limited to:

• 90° APF; OR
• Hill repair; OR

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Lind partial fundoplication⁶ These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about hiatal hernia may be found from the following websites:

Background

• American College of Gastroenterology
• American Gastroenterological Association
• National Library of Medicine

Medical Alternatives

Alternatives to laparoscopic hiatal hernia include, but may not be limited to, the following:

• Open hiatal hernia procedure

Physician consultation is advised to make an informed decision based on an individual's health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.