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.
