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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 13.1
Digestive System
Issue Date:  August 26, 1985
Authority:  32 CFR 199.4(c)(2) and (c)(3)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-32, August 31, 2018
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).
4.3  For bariatric procedures, see Section 13.2.
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.
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