This file addresses paraesophageal hernia (PEH) repair. This file does not address sliding hiatal hernia fix or surgical measures for the therapy of Barrett’s Esophagus.

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Clinical Indications

Medically Necessary:

Paraesophageal hernia repair is thought about medically necessary for symptomatic people with all of the complying with indications:A paraesophageal hernia is prove on diagnostic imaging or endoscopic study; andOne the the following conditions exists:Gastric outlet obstruction resulted in by the hernia; orPersistent anemia without various other identified reasons after evaluation; orSuspected or recorded gastric strangulation; orGastroesophageal reflux symptoms unresponsive to medical treatment.Paraesophageal hernia repair throughout a gastric operation procedure, including yet not minimal to bariatric surgery, is thought about medically necessary once a paraesophageal hernia has actually been detected.Recurrent paraesophageal hernia fix is taken into consideration medically necessary once all that the criteria below are met:A paraesophageal hernia is prove on diagnostic imaging or endoscopic examine performed after the vault repair; andA condition listed in standard A stubborn or recurs:Gastric outlet obstruction resulted in by the hernia; orPersistent anemia without other identified cause after evaluation; orSuspected or recorded gastric strangulation; orGastroesophageal reflux symptom unresponsive to clinical treatment.

Not median Necessary:

Paraesophageal hernia repair is thought about not medically necessary once the criteria above are no met and also for all other indications, including yet not limited to asymptomatic people not experience gastric surgery or during surgery for various other than gastric indications.


The adhering to codes for treatments and procedures applicable come this reminder are included listed below for informational purposes. Inclusion or exemption of a procedure, diagnosis or maker code(s) does not constitute or indicate member coverage or provider reimbursement policy. Please describe the member's contract services in impact at the time of service to determine coverage or non-coverage that these services as it applies to an separation, personal, instance member.

When services might be Medically crucial when criteria room met:For the codes provided below only as soon as specified that a paraesophageal hernia repair to be completed



Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures)


Laparoscopy, surgical, fix of paraesophageal hernia, includes fundoplasty, as soon as performed; there is no implantation that mesh


Laparoscopy, surgical, repair of paraesophageal hernia, contains fundoplasty, once performed; with implantation of mesh


Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty)


Esophagogastric fundoplasty, v fundic patch (Thal-Nissen procedure)


Esophagogastric fundoplasty partial or complete; laparotomy


Esophagogastric fundoplasty partial or complete; thoracotomy


Esophagomyotomy (Heller type); abdominal approach


Esophagomyotomy (Heller type); thoracic approach


Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, other than neonatal; without implantation that mesh or other prosthesis


Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, other than neonatal; v implantation the mesh or various other prosthesis


Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or various other prosthesis


Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, other than neonatal; through implantation of mesh or other prosthesis


Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; there is no implantation of mesh or other prosthesis


Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, other than neonatal; with implantation that mesh or various other prosthesis


Esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty)

ICD-10 Procedure


Repair diaphragm


Supplement diaphragm with man-made substitute

ICD-10 Diagnosis

All diagnoses, including, but not minimal to:


Iron deficiency anemia second to blood loss (chronic)


Anemia, unspecified


Acute posthemorrhagic anemia


Gastro-esophageal reflux disease


Adult hypertrophic pyloric stenosis


Other diseases of stomach and duodenum


Diaphragmatic hernia


Congenital hiatus hernia


Congenital diaphragmatic hernia



When services are no Medically Necessary:For the procedure codes listed above as soon as criteria space not met or for situations designated in the Clinical Indications section as not medically necessary.

Discussion/General Information

PEH is a form of hiatal hernia, i beg your pardon is a protrusion the an abdominal structure, other than the esophagus, into the chest cavity. Hiatal hernias space categorized into species I – IV. The culture of American Gastrointestinal and also Endoscopic surgeons (SAGES) released guidelines because that the administration of hiatal hernia (Kohn, 2013) v the complying with classifications:

Type ns hernias are sliding hiatal hernias, whereby the gastroesophageal junction migrates over the diaphragm. The stomach stays in its normal longitudinal alignment and also the fundus remains listed below the gastroesophageal junction.Type II hernias are pure paraesophageal hernias (PEH); the gastroesophageal junction remains in its typical anatomic position yet a section of the fundus herniates v the diaphragmatic hiatus nearby to the esophagus.Type III hernias space a combination of types I and also II, v both the gastroesophageal junction and the fundus herniating with the hiatus. The fundus lies above the gastroesophageal junction.Type IV hiatal hernias are identified by the presence of a structure other than stomach, such together the omentum, colon or tiny bowel in ~ the hernia sac.

The bulk of hiatal hernias are type I, which room sliding hiatal hernias. Varieties II – IV are considered PEH with type III gift the most common and type II being the least common.

PEH have the right to be repaired v an open or laparoscopic transabdominal technique or v thoracotomy. As result of less postoperative pain, diminished rate the morbidity, and much shorter hospital stays, SAGES proposal laparoscopic repair as the preferred technique (Kohn, 2013). Several retrospective studies resulted in comparable conclusions (Boushey, 2008; Dallemagne, 2011; El Khoury, 2015; Kubasiak, 2014). Other surgical procedures that are periodically used in enhancement to PEH repair include hernia sac excision, reinforced repair through the usage of mesh, fundoplication, mediastinal dissection that the esophagus, Collis gastroplasty, gastropexy, and also gastrostomy pipe insertion. The literary works on these technical considerations consists of greatly low top quality retrospective reports with small sample sizes and also inadequate study designs.

Past studies have argued PEH repair because that both symptomatic and asymptomatic PEH; however, an ext recent studies indicate that PEH repair must only be performed in individuals with gastric outlet obstruction, major gastroesophageal reflux, major anemia, or feasible gastric strangulation due to the fact that asymptomatic PEH is safe to observe. In addition, PEH fix in asymptomatic individuals deserve to decrease the quality-adjusted life expectations for those age 65 years and also older (Kohn, 2013). For people with gastroesophageal reflux, the American university of Gastroenterology proposal non-surgical management of gastroesophageal reflux before surgical treatment. Interventions in the administration of gastroesophageal reflux encompass weight loss counseling and attempting load loss, head of bed elevation, avoidance of meals 2 come 3 hours before bedtime, elimination of foodstuffs that cause reflux (for example, chocolate, caffeine, acidic foods, and spicy foods), tobacco and also alcohol cessation, optimizing proton pump inhibitor therapy, excluding various other etiologies, and reflux monitoring (Katz, 2013). Recurrent PEH repair is shown when the symptoms enhance anatomical result (Kohn, 2013), which occurs in 25.5% of main PEH repair (Rathore, 2007).

Some retrospective studies have reported gastroesophageal reflux as a complication after bariatric surgical treatment that deserve to lead come reoperation and concluded the hiatal hernias must be repaired if detected during these steps (Dolan, 2003; El Chaar, 2016; Frezza, 2008). Another larger retrospective examine (Gulkarov, 2008) the review charts of all individuals over a 5-year period who had actually laparoscopic adjustable gastric banding (n=1298) with an average follow-up the 24.8 months, and those who had laparoscopic adjustable gastric banding with concurrent hiatal hernia fix (n=520) v an average follow-up of 20.5 months. The authors discovered that adding hiatal hernia fix to laparoscopic adjustable gastric banding caused a far-reaching reduction in the number of reoperations for tape slippage, pouch dilation, and also hiatal hernia (pDefinitions

Anemia: A condition of having actually too couple of red blood cells. Healthy red blood cells lug oxygen transparent the body. If the blood is short on red blood cells, the body does no get sufficient oxygen.

Collis gastroplasty: A operation procedure come lengthen the esophagus.

Fundoplication: A operation procedure design to gain back the barrier role of the lower esophageal sphincter. The many common kind of fundoplication procedure is referred to as Nissen fundoplication, which is typically performed laparoscopically.

Gastric banding: This operation procedure is to plan to help a human lose weight. A band is placed approximately the upper component of the stomach, creating a small pouch that have the right to hold just a little amount of food. The narrowed opening between the stomach pouch and also the remainder of the stomach controls how quickly food passes from the pouch to the lower component of the stomach. This mechanism helps the human being to eat less by limiting the lot of food that can be eaten at one time and also increasing the time it takes for food to it is in digested.

Gastric bypass: This surgical procedure reduces the stomach capacity and diverts partially digested food indigenous the duodenum to the jejunum (section the the little intestine prolonging from the duodenum).

Gastric outlet obstruction: A problem caused by any an illness process the blocks emptying of the stomach.

Gastric strangulation: A problem caused by a hernia that cuts off blood it is provided to the intestines and tissues in the abdomen.

Gastroesophageal reflux: A problem caused through chronic back-flow of acid from the stomach right into the esophagus, leading to heartburn and leading to irritation and possible damage to the lining of the esophagus.

Gastropexy: A operation procedure designed come suture the stomach to the ab wall.

Thoracotomy: A operation procedure to open up and access an individual’s chest.


Peer the evaluation Publications:

Boushey RP, Moloo H, Burpee S, et al. Laparoscopic fix of paraesophageal hernias: a Canadian experience. Can J Surg. 2008; 51(5):355-360.Dallemagne B, Kohnen L, Perretta S, et al. Laparoscopic repair of paraesophageal hernia. Permanent follow-up reveals great clinical outcome in spite of high radiological recurrence rate. Ann Surg. 2011; 253(2):291-296.Davis M, Rodriguez J, El-Hayek K, et al. Paraesophageal hernia repair with partial longitudinal gastrectomy in obese patients. JSLS. 2015; 19(3):e2015.00060.Dolan K, Finch R, and Fielding G. Laparoscopic gastric banding and also crural fix in the obese patient v a hiatal hernia. Obes Surg. 2003; 13(5):772-775.El Chaar M, Ezeji G, Claros L, et al. Short-term outcomes of laparoscopic sleeve gastrectomy in combination with hiatal hernia repair: endure in a single accredited center. Obes Surg. 2016; 26(1):68-76.El Khoury R, Ramirez M, Hungness ES, et al. Symptom relief after ~ laparoscopic paraesophageal hernia fix without mesh. J Gastrointest Surg. 2015; 19(11):1938-1942.Frezza EE, Barton A, and also Wachtel MS. Crural fix permits morbidly obese patients v not big hiatal hernia to select laparoscopic flexible banding together a bariatric surgical treatment. Obes Surg. 2008; 18(5):583-588.Furnée EJ, Draaisma WA, Simmermacher RK, et al. Irreversible symptomatic outcome and radiologic evaluate of laparoscopic hiatal hernia repair. To be J Surg. 2010; 199(5):695-701.Gulkarov I, Wetterau M, Ren CJ, and also Fielding GA. Hiatal hernia repair at the initial laparoscopic adjustable gastric band operation reduces the need for reoperation. Surg Endosc. 2008; 22(4):1035-1041.Jones R, Simorov A, Lomelin D, et al. Irreversible outcomes of radiologic recurrence ~ paraesophageal hernia repair through mesh. Surg Endosc. 2015; 29(2):425-430.Kao AM, Otero J, Schlosser KA, et al. One much more time: redo paraesophageal hernia repair outcomes in safe, sturdy outcomes contrasted with primary repairs. Am Surg. 2018; 84(7):1138-1145.Kubasiak J, Hood KC, Daly S, et al. Enhanced patient outcomes in paraesophageal hernia repair utilizing a laparoscopic approach: a examine of the nationwide surgical quality improvement program data. To be Surg. 2014; 80(9):884-889.Latzko M, Borao F, Squillaro A, et al. Laparoscopic fix of paraesophageal hernias. JSLS. 2014; 18(3).Lazar DJ, Birkett DH, Brams DM, et al. Irreversible patient-reported outcomes the paraesophageal hernia repair. JSLS. 2017; 21(4).Lidor AO, Steele KE, Stem M, et al. Irreversible quality of life and risk determinants for recurrence after ~ laparoscopic repair of paraesophageal hernia. JAMA Surg. 2015; 150(5):424-431.Nason KS, Luketich JD, Qureshi I, et al. Laparoscopic repair of giant paraesophageal hernia outcomes in irreversible patient satisfaction and also a resilient repair. J Gastrointest Surg. 2008; 12(12):2066-2077.Rathore MA, Andrabi SI, Bhatti MI, et al. Meta-analysis the recurrence ~ laparoscopic fix of paraesophageal hernia. JSLS. 2007; 11(4):456-460.Targarona EM, Grisales S, Uyanik O, et al. Irreversible outcome and quality of life after laparoscopic therapy of big paraesophageal hernia. Civilization J Surg. 2013; 37(8):1878-1882.

Government Agency, medical Society, and Other authoritative Publications:

Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management the gastroesophageal reflux disease. Am J Gastroenterol. 2013; 108(3):308-328.Kohn GP, Price RR, DeMeester SR, et al. Guidelines for the administration of hiatal hernia. Surg Endosc. 2013; 27(12):4409-4428.

Adjustable Gastric BandingBariatric SurgeryFundoplicationGastric BypassHiatal Hernia






Medical policy & technology Assessment Committee (MPTAC) review. Updated referral Section. Reformatted Coding section.


MPTAC review. Modification Medically crucial Clinical Indications because that paraesophageal hernia repair throughout gastric surgical procedures. To update Description and also Coding sections.


MPTAC review. Initial paper development.

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