CG-SURG-92 Paraesophageal Hernia Repair

This policy addresses surgical repair of paraesophageal hernia (PEH). Coverage is medically necessary for symptomatic individuals when a PEH is confirmed by imaging or endoscopy and at least one of the following is present: gastric outlet obstruction from the hernia, persistent anemia without other identified cause, suspected or documented gastric strangulation, or gastroesophageal reflux symptoms unresponsive to medical therapy. It is not medically necessary if these criteria are not met, including in asymptomatic individuals not undergoing gastric surgery or when performed during surgery for non-gastric indications.

"Paraesophageal hernia repair is consideredmedically necessaryfor symptomatic individuals withallof the following indications:A paraesophageal hernia is demonstrated on diagnostic imaging or endosco..."

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