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