ModifiedKaiser PermanentePolicy N/A

Non Hiatal Hernia

Clinical review criteria governing medical necessity determinations for non-hiatal (anterior abdominal and groin) hernia repairs for Kaiser Foundation Health Plan of Washington members; includes Medicare and non-Medicare pathways and applicable CPT and ICD-10 codes and references to MCG guideline criteria for elective surgical level-of-care reviews.

Policy Summary

PayerKaiser Permanente

PolicyNon Hiatal Hernia

Policy CodePolicy N/A

Change TypeNew hybrid criteria adopted

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionWhen requesting non-hiatal hernia repair, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

MPC approved to adopt new hybrid criteria for Non-Hiatal Hernia Repair for non-Medicare & Medicare members.

7CPT/Unlisted Codes Listed

2ICD-10 Diagnosis Codes Listed

Coverage Summary

Overview: This policy sets clinical review criteria governing medical necessity determinations for non-hiatal (anterior abdominal and groin) hernia repairs for Kaiser Foundation Health Plan of Washington members. Coverage stance: mixed. Effective date: 2025-11-01. Status: MODIFIED. For Non‑Medicare members, Kaiser reviews elective surgical level-of-care requests using the MCG Hernia Repair (non-hiatal) KP-S-1305 care guideline. For Medicare members, Kaiser uses its own Non-Hiatal Hernia Repair clinical review criteria because CMS guidance is absent. Applicable CPT and ICD-10 code lists are provided in the policy.

Medical-Necessary Criteria & Review Process

General Medical Necessity / Review Process

Covered when ALL of the following are met:

ALL of the following

For non-Medicare members: review using MCG Hernia Repair (non-hiatal) KP-S-1305 10012025 MCG Care Guideline for medical necessity determinations; MCG criteria apply to elective surgical procedure level of care determinations.
For Medicare members: Kaiser Permanente Clinical Review Criteria 'Non-Hiatal Hernia Repair' will be used for medical necessity determinations in the absence of applicable CMS or MAC coverage guidance.
Documentation: provide the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity review.
Applicable CPT codes (including but not limited to 49591, 49593, 49595, 49613, 49615, 49617, 49659) are considered medically necessary only when the above criteria are met and when reviewed against the Elective Surgical (Level of Care) policy.

Exclusions / Notes

The following exclusions/notes apply (ALL):

ALL of the following

Strangulated or incarcerated hernia repairs are excluded from the elective surgical (level of care) policy and are managed as emergent procedures; codes specific to strangulated/incarcerated repairs are not to be processed under this elective policy.
Elective policy does not limit coverage of emergent repairs—emergent clinical indications (eg, loss of blood supply, bowel obstruction from hernia) should be documented and processed according to emergent care pathways and applicable benefit terms.

Relevant Codes

Considered Medically Necessary when criteria met (Hernia repair CPT codes)CPTCovered

49591	Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible.
49593	Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, reducible.
49595	Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, reducible.
49613	Repair of anterior abdominal hernia(s)... recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible.
49615	Repair of anterior abdominal hernia(s)... recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, reducible.
49617	Repair of anterior abdominal hernia(s)... recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); greater than 10 cm, reducible.
49659	Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy.

Diagnosis codes referencedICD-10

K42.0	Umbilical hernia with obstruction, without gangrene.
K42.9	Umbilical hernia without obstruction or gangrene.

Billing caution: Codes listed in the policy may not be all-inclusive. Deleted codes and codes not in effect at the time of service may not be covered; verify code validity and plan-specific authorization requirements (for example, via the Pre-authorization Code Check) before submitting a request.

Provider Actions & Authorization

Prior Authorization

Pre-authorization / Review requirement

Authorization and review requirements follow the Elective Surgical (Level of Care) policy and the MCG Hernia Repair (non-hiatal) KP-S-1305 guideline. Verify plan-specific pre-authorization requirements using the Pre-authorization Code Check.

49591
49593
49595
49613
49615
49617
49659

Documentation Required

Submission of clinical notes

When requesting non-hiatal hernia repair, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

Billing Rule

Deleted or inactive codes caution

Codes listed may not be all-inclusive. Deleted codes and codes not in effect at the time of service may not be covered — verify code validity and authorization for the planned date of service.

Background & Evidence

Background: Non-hiatal hernias occur when abdominal contents push through a weakness in the abdominal wall and commonly include inguinal, umbilical, ventral, and incisional hernias. These defects can present as a visible bulge and range from asymptomatic to painful. Complications include incarceration (trapping of tissue) and strangulation (loss of blood supply), which are medical emergencies. Complication rates differ by hernia type: umbilical hernias generally have lower incarceration/complication rates, whereas incisional and some groin hernias show higher rates of incarceration and strangulation. Larger defect size, a high hernia‑neck ratio, and comorbidities increase the risk of complications. Kaiser Permanente lacked an existing non-hiatal hernia medical policy and therefore adopted MCG criteria for non-Medicare members and developed its own Medicare pathway due to absent CMS guidance.

Key references: Sneiders 2019; Baker 2024; Derici 2007; WSES 2013.