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Date Printed: May 21, 2018: 06:06 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-46000-01

Original Effective Date: 05/15/12

Reviewed: 03/22/18

Revised: 04/15/18

Subject: High Resolution Anoscopy

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

High resolution anoscopy (HRA), also known as colposcopy of the anal canal, is a procedure which allows for examination and evaluation of the anal canal using an anoscope and a high resolution (10 - 40x magnification) colposcope. The anal canal is examined following the application of a mild acidic liquid that aides in the identification of abnormal tissue such as anal dysplasia. If suspicious lesions are found, biopsies are obtained for microscopic examination.

POSITION STATEMENT:

High resolution anoscopy meets the definition of medical necessity when used in the diagnosis of a suspicious anal lesion (including a high-grade suspicious intraepithelial lesion) OR anal dysplasia found in prior cytology/biopsy.

High resolution anoscopy is considered experimental or investigational for all other indications and when used as a screening test for anal dysplasia and anal cancer. The evidence is insufficient to determine the effects of the technology on health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

46601

Anoscopy; diagnostic, with high-resolution magnification (HRA) (e.g., colposcope, operating microscope) and chemical agent enhancement, including collection of specimen(s) by brushing or washing, when performed

46607

Anoscopy; with high-resolution magnification (HRA) (e.g., colposcope, operating microscope) and chemical agent enhancement, with biopsy, single or multiple

ICD-10 Diagnoses Codes That Support Medical Necessity:

A63.0

Anogenital (venereal) warts

C21.0

Malignant neoplasm of anus, unspecified

C21.1

Malignant neoplasm of anal canal

C78.5

Secondary malignant neoplasm of large intestine and rectum

D01.3

Carcinoma in situ of anus and anal canal

D12.7 D12.9

Benign neoplasm of rectum, anus, and anal canal

K62.0

Anal polyp

K62.1

Rectal polyp

K62.5

Hemorrhage of anus and rectum

K62.6

Ulcer of anus and rectum

K62.7

Radiation proctitis

K62.81K62.89

Other specified diseases of anus and rectum

R85.610 R85.619

Abnormal cytologic smear of anus

REIMBURSEMENT INFORMATION:

Refer to sections entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Noncovered Services (L33777) located at fcso.com.

DEFINITIONS:

Anal dysplasia: Anal cells that look abnormal under a microscope but are not cancer.

RELATED GUIDELINES:

None applicable.

OTHER:

None.

REFERENCES:

  1. Agency for Healthcare Research and Quality (AHRQ). Healthcare Horizon Scanning System AHRQ – Potential High-Impact Interventions Report. Priority Area 09: Infectious Disease Including HIV/AIDS. June 2013.
  2. American Cancer Society. Detailed Guide: Anal Cancer What Is Anal Cancer? Accessed 03/14/13.
  3. American Society for Colposcopy and Cervical Pathology. Practice Management, Anus. Accessed 03/06/13.
  4. Berry JM, Palefsky JM, Jay N, Cheng SC, Darragh TM, Chin-Hong PV. Performance characteristics of anal cytology and human papillomavirus testing in patients with high-resolution anoscopy-guided biopsy of high-grade anal intraepithelial neoplasia. Dis Colon Rectum. 2009 Feb;52(2):239-47.
  5. ClinicalTrials.gov, The Overlooked Population at Risk for AIN: Women With High-grade Lower Genital Tract Dysplasia or Cervical Cancer, sponsored by Sunnybrook Health Sciences Centre, accessed 02/18.
  6. ClinicalTrials.gov, Screening for Anal Cancer in Women With High-grade Vulvar Dysplasia or Vulvar Cancer, sponsored by Dr. Danielle Vicus; accessed 02/18.
  7. Echenique I, Phillips BR. Anal Warts and Anal Intradermal Neoplasia. Clin Colon Rectal Surg 2011;24:31–38.
  8. First Coast Service Options, Florida Local Coverage Determination (LCD) Noncovered Services (L3777); accessed at fcso.com.
  9. Gimenez F, Costa-e-Silva IT, Daumas A, Ara├║jo J, Medeiros SG, Ferreira L. The value of high-resolution anoscopy in the diagnosis of anal cancer precursor lesions in HIV-positive patients. Arq Gastroenterol. 2011 Jun;48(2):136-45.
  10. Kaplan JE, Benson C, Holmes KH, et al, Centers for Disease Control and Prevention (CDC), National Institutes of Health, HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep 2009;58(RR-4):1-207.
  11. National Cancer Institute website. Anal Cancer Screening Study (accessed 03/18/13).
  12. National Comprehensive Cancer Network (NCCN) Clinical Practice Guideline- Anal Carcinoma, Version 1.2018; accessed at nccn.org.
  13. Pineda CE, Berry JM, Welton ML. High resolution anoscopy and targeted treatment of high-grade squamous intraepithelial lesions. Dis Colon Rectum. 2006 Jan;49(1):126.
  14. Steele SR, Varma MG, et al, Practice parameters for anal squamous neoplasms. Dis Colon Rectum. 2012 Jul;55(7):735-49.
  15. Weis SE, Vecino I, Pogoda JM, Susa JS, Nevoit J, Radaford D, McNeely P, Colquitt CA, Adams E. Prevalence of anal intraepithelial neoplasia defined by anal cytology screening and high-resolution anoscopy in a primary care population of HIV-infected men and women. Dis Colon Rectum. 2011 Apr;54(4):433-41.
  16. Wilkin TJ. Screening for anal cancer: Who, when, and how. Medscape HIV/AIDS. New York, NY: Medscape; April 22, 2010. Accessed 04/18/12.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/22/18.

GUIDELINE UPDATE INFORMATION:

05/15/12

New Medical Coverage Guideline.

05/15/13

Scheduled review; position statement unchanged, Program Exceptions section updated, references updated.

04/15/14

Annual review; position statement unchanged; references updated.

01/01/15

Annual coding update: removed 0226T and 0227T; added 46601 and 46607.

11/01/15

Revision: ICD-9 Codes deleted.

01/01/16

Annual HCPCS/CPT update; codes G6027 and G6028 deleted.

10/01/16

Revision; coding section updated; formatting changes.

04/15/18

Review; Update position statements, description, coding, and references.

Date Printed: May 21, 2018: 06:06 PM