43328
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
19.41
Facility
$1061.15
Non-Facility
$1061.15
Key Coverage Criteria
- Paraesophageal hernia repair during a gastric surgical procedure, including but not limited to bariatric surgery, is consideredmedically necessarywhen a paraesophageal hernia has been detected.
- Paraesophageal hernia repair is consideredmedically necessaryfor symptomatic individuals withallof the following indications:A paraesophageal hernia is demonstrated on diagnostic imaging or endoscopic study;andOne of the following conditions exists:Gastric outlet obstruction caused by the hernia;orPersistent anemia without other identified causes after evaluation;orSuspected or documented gastric strangulation;orGastroesophageal reflux symptoms unresponsive to medical treatment.
- A paraesophageal hernia is demonstrated on diagnostic imaging or endoscopic study;and
- One of the following conditions exists:Gastric outlet obstruction caused by the hernia;orPersistent anemia without other identified causes after evaluation;orSuspected or documented gastric strangulation;orGastroesophageal reflux symptoms unresponsive to medical treatment.
- Gastric outlet obstruction caused by the hernia;or
- Persistent anemia without other identified causes after evaluation;or
2 Active Policies
ANTHEM-CG-SURG-92 — CG-SURG-92 Paraesophageal Hernia Repair
REGENCE-SUR186 — Gastroesophageal Reflux Surgery
Related Codes
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