Policy Updates Medical Policy & Clinical GuidelinesCommercialFebruary 29, 2020

Clinical Guideline Update - June 2020

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

The following new Empire BlueCross BlueShield (“Empire”) Clinical Guideline will require prior authorization review effective June 1, 2020.

 

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 (NMN) 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,

0BUT0JZ will be reviewed for MN criteria

 

PUBLICATIONS: March 2020 Empire Provider News