Humana Laparoscopic Hiatal Hernia Repair - Medicare Advantage Form

Please refer to CMS website for the most current applicable CMS Online Manual System (IOMs)/National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/ Transmittals. There are no NCDs and/or LCDs for Laparoscopic Hiatal Hernia Repair. Laparoscopic Hiatal Hernia Repair Page: 2 of 4 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 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. Types of fundoplication procedures include, but may not be limited to: • 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: o 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. o 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. o 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. o 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. o 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 as compared to the Nissen fundoplication, which may help an individual with impaired esophageal motility. Laparoscopic Hiatal Hernia Repair Page: 3 of 4 Coverage Determination Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare. In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the following criteria: Laparoscopic Hiatal Hernia Repair The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy. In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider MCG Guidelines. Coverage Limitations US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage