1.0 CPT 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) 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 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 a United States (US) Food and Drug Administration (FDA) approved
electrosurgical cutting and coagulation device.
3.4 Intraperitoneal Hyperthermic
Chemotherapy (IPHC) (CPT 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 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 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
4.2 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 codes 43201 and 43257).
4.4 RFA for
treatment of liver metastases from primary sites other than colorectal
metastases is unproven (CPT 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
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 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 code 0184T) for treatment
of benign lesions or malignant T1 tumors is covered effective June
2, 2009.
5.4 THD (CPT
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.