1.0 CPT
PROCEDURE CODES
40490 - 40831, 40899 - 43644,
43647, 43648, 43651 - 43761, 43800, 43810, 43820, 43842, 43846, 43848,
43880 - 43882, 43999, 44005 - 47362, 47370, 47371, 47379 - 47382,
47399 - 49999, 91123, 96570, 96571
2.0 DESCRIPTION
The digestive system involves the organs associated
with the ingestion, digestion, and absorption of nutrients, and
the elimination of solid waste.
3.0 POLICY
3.1 Services
and supplies required in the diagnosis and treatment of illness
or injury involving the digestive system are covered.
3.2 Gastric
electrical stimulation (Current Procedural Terminology (CPT) procedure
codes 43647, 43648, 43881, and 43882) for treatment of symptoms
of nausea and vomiting from chronic gastroparesis that is refractory
to medical management may be considered for coverage as a Humanitarian
Use Device (HUD).
3.3 Radiofrequency Ablation (RFA)
(CPT procedure codes 47370, 47380, and 47382) for treatment of unresectable
hepatocellular carcinoma or unresectable liver metastases from colorectal
cancer is proven and may be covered when all of the following conditions
are met:
• Tumors
are less than five centimeters in diameter;
• There are five
or fewer tumors; and
• There is no evidence
of extrahepatic metastasis.
Note: All procedures must be performed using an U.S.
Food and Drug Administration (FDA) approved electrosurgical cutting
and coagulation device.
3.4 Intraperitoneal Hyperthermic
Chemotherapy (IPHC) (CPT procedure codes 77600, 77605, and 96445)
in conjunction with cytoreductive surgery or peritonectomy for treatment
of pseudomyxoma peritonei resulting from appendiceal carcinoma may
be covered under the Rare Diseases policy on a case-by-case basis
for adult patients when all of the following criteria are met:
• There
is no evidence of distant metastasis.
• There is evidence
of low histological aggressiveness of the disease.
• The patient’s condition
does not preclude major surgery.
• The chemotherapeutic
agents used are mitomycin C, cisplatin (also known as cisplatinum), or
fluorouracil.
3.5 Transanal Endoscopic Microsurgery
(TEM) (CPT procedure code 0184T) for treatment of benign lesions
or malignant T1 tumors is proven and may be covered when all of
the following criteria are met:
• The lesion can be
adequately identified in the rectum and is a mobile, non-fixed benign lesion
or T1 tumor with a diameter less than three centimeters that covers
less than 30% of the circumference of the bowel, located within
eight centimeters of the anal verge.
• Pretreatment endorectal
ultrasonography indicates an absence of lymphadenopathy and microscopic
angiolymphatic invasion.
• The tumor is a moderately
or well differentiated grade I, with no lymphatic, vascular, or perineural
invasion.
• Resection
margins are negative for greater than three millimeters.
• There is no evidence
of distant metastasis.
3.6 Transanal Hemorrhoidal Dearterialization (THD)
(CPT procedure code 0249T) as an alternative to conventional internal
hemorrhoidectomy for the treatment of grade II to IV hemorrhoids
is proven.
3.7 Surgery for total, complete,
or partial ankyloglossia may be covered when medically necessary (e.g.,
feeding, eating, swallowing or speech difficulties exist).
3.8 Cytoreductive Surgery (CRS) with
Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for treatment
of Peritoneal Carcinomatosis (PC) secondary to colorectal cancer
is proven.
4.0 EXCLUSIONS
4.1 Vestibuloplasty
(CPT procedure codes 40840 - 40845) EXCEPT for adjunctive dental
care (see
Chapter 8, Section 13.1).
4.2 The Stretta
System (Curon Medical, Sunnyvale, CA), Bard Endoscopic Suturing
System, and Transoral Incisionless Fundoplication using EsophyX
(EndoGastric Solutions, Redmond, WA) for the treatment of refractory
Gastro-Esophageal Reflux Disease (GERD) are unproven (CPT procedure
codes 43201 and 43257).
4.4 RFA for treatment of liver
metastases from primary sites other than colorectal metastases is unproven
(CPT procedure codes 47370, 47380,
and 47382).
4.5 Magnetic
sphincter augmentation with the LINX™ Reflux Management System for
the treatment of GERD is unproven.
5.0 Effective
Dates
5.1 RFA (CPT procedure codes 47370, 47380, and
47382) for treatment of unresectable hepatocellular carcinoma or
unresectable liver metastases from colorectal cancer is proven and covered,
effective April 28, 2004.
5.2 IPHC (CPT procedure codes
77600, 77605, and 96445) in conjunction with cytoreductive surgery
or peritonectomy for treatment of pseudomyxoma peritonei arising
from appendiceal carcinoma may be covered under the Rare Diseases
policy on a case-by-case basis for adult patients, effective May
13, 2009.
5.3 TEM (CPT procedure code 0184T) for treatment
of benign lesions or malignant T1 tumors is covered effective June
2, 2009.
5.4 THD (CPT procedure code 0249T)
is covered effective October 28, 2013.
5.5 CRS with HIPEC for treatment
of PC secondary to colorectal cancer is covered effective February 1,
2017.