Policy Updates Medical Policy & Clinical GuidelinesCommercialFebruary 29, 2020

Clinical guideline update effective June 1, 2020 - Paraesophageal Hernia Repair

recertification review will be required effective June 1, 2020 for the following new Anthem Clinical Guideline.

CG-SURG-92

Paraesophageal

Hernia Repair

• PEH repair is considered medically necessary (MN) for symptomatic individuals when criteria are met

• PEH repair during operation for

Roux-en-Y gastric bypass, sleeve gastrectomy, or the placement of an adjustable gastric band is considered MN when criteria are met

• Recurrent PEH repair is considered MN when criteria are met

• PEH repair is considered not medically necessary when criteria are not met and for all other indications

Existing codes

43280, 43281, 43282, 43283, 43325, 43327,

43328, 43330, 43331, 43332, 43333, 43334,

43335, 43336, 43337, 43338, 0BQT0ZZ,

0BQT3ZZ, 0BQT4ZZ and 0BUT0JZ will be reviewed for MN criteria

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