Summary
Initial esophagogastric fundoplication for symptomatic gastroesophageal reflux disease may be considered medically necessary when no paraesophageal hiatal hernia repair is requested or documented, symptoms are unresponsive to lifestyle modifications, a medication requirement is met (a 4-month total trial of proton pump inhibitors that is ineffective, contraindicated or not tolerated, or PPIs used for 12 or more consecutive months within the past 18 months with surgery considered an alternative to long-term medication), and reflux is objectively confirmed by endoscopy or, if endoscopy is normal, by 24-hour ambulatory esophageal pH monitoring or barium swallow. Fundoplication may also be considered medically necessary for children and adolescents age 17 or younger, for individuals with pulmonary fibrosis and symptomatic or asymptomatic reflux, for a confirmed paraesophageal hiatal hernia (Types II-IV), for esophageal myotomy in achalasia, and for repeat fundoplication after a documented mechanical failure. Gastrectomy, gastrojejunostomy as a stand-alone treatment, and hiatal hernia repair without fundoplication are considered investigational for gastroesophageal reflux.
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