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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.

02-45000-01

Original Effective Date: 02/26/09

Reviewed: 02/23/12

Revised: 05/15/14

Subject: Transanal Endoscopic Microsurgery (TEM)

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 Update  

DESCRIPTION:

Transanal endoscopic microsurgery (TEM) involves the use of specialized equipment including an operating proctoscope, insufflation, and magnified stereoscopic views for resection of rectal tumors. Use of this equipment deals with limitations on local resection due to the anal sphincter and boney confines of the pelvis. Lesions that could not be removed through the anus under usual circumstances become accessible with the use of TEM. Use of this technique should not change the type of rectal lesion that is or is not removed by a localized resection; this only changes the surgical approach.

As noted, this procedure requires use of specialized equipment. The Transanal Endoscopic Microsurgery (TEM) Combination System and Instrument Set (Richard Wolf Medical Instruments Corp) received 510(k) marketing clearance from the U.S. Food and Drug Administration (FDA) in 2001.

POSITION STATEMENT:

Transanal endoscopic microsurgery meets the definition of medical necessity for the treatment of rectal adenomas, including recurrent adenomas that cannot be removed using other means of local excision.

Transanal endoscopic microsurgery meets the definition of medical necessity for treatment of clinical stage T1 rectal adenocarcinomas than cannot be removed using other means of local excision when ALL of the following criteria are met:

Transanal endoscopic microsurgery is considered investigational or experimental for the treatment of rectal tumors that do not meet the criteria noted above as there are insufficient published clinical studies to determine health outcomes or long- term effects of this procedure.

BILLING/CODING INFORMATION:

The following code may be used to describe transanal endoscopic microsurgery (TEM):

CPT Coding:

0184T

Excision of rectal tumor, transanal endoscopic microsurgical approach (i.e., TEM) ), including muscularis propria (i.e., full thickness)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Endoscopy (100.2) located at cms.gov.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. American Society for Gastrointestinal Endoscopy – Communication from ASGE Standards of Practice Committee; Guideline – Role of Endoscopic Ultrasound; Gastrointestinal Endoscopy; Vol 66, No 3: 2007.
  2. American Society of Clinical Oncology. Multi-modality approach in curative local treatment of early rectal carcinomas – 12 years Liverpool experience (2004).
  3. American Society of Clinical Oncology. Transanal Endoscopic Microsurgery for Rectal Lesions (1999).
  4. Bach SP, Hill J, Monson JR, Simson JN, Lane L, Merrie A, Warren B, Mortensen NJ. A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer. Association of Coloproctology of Great Britain and Ireland Transanal Endoscopic Microsurgery (TEM) Collaboration. Br J Surg. 2009 Mar; 96(3): 280-90. PMID: 19224520 [PubMed – indexed for MEDLINE].
  5. Blue Cross and Blue Shield Association. Medical Policy Reference Manual. 7.01.112 Transanal Endoscopic Microsurgery. 11/11/10.
  6. Centers for Medicare and Medicaid Services (CMS) Manual System, Pub. 100-3, Medicare National Coverage, Chapter 1, Part 2, Section 100.2 Endoscopy. 10/03/03.
  7. Christoforidis D, et al. Transanal endoscopic microsurgery versus conventional transanal excision for patients with early rectal cancer. Ann Surg. 2009 May; 249(5): 776-82 PMID: 19387326 [PubMed – indexed for Medline].
  8. Darwood RJ, Wheeler JMD, Borley NR. Transanal endoscopic microsurgery is a safe and reliable technique even for complex rectal lesions. Brit J of Surg 95(7): 915-918. Published online 05/21/08.
  9. Dias AR, Nahas CS, Marques CF, Nahas SC, Cecconello I. Transanal endoscopic microsurgery: indications, results and controversies. Tech Coloproctol. 2009 Jun; 13(2): 105-11. Epub 2009 May 29. PMID: 19484350 [PubMed – in process].
  10. Doornebosch PG, Gosselink MP, Neijenhuis PA, Schouten WR, Tollenaar RA, de Graaf EJ. Impact of transanal endoscopic microsurgery on functional outcome and quality of life. Int J Colorectal Dis. 2008 Jul; 23(7):709-13. Epub 2008 Apr 1. PMID: 18379797 [PubMed – indexed for MEDLINE].
  11. ECRI Institute’s Health Technology Assessment Information Service (HTAIS) Hotline Response article. Transanal Endoscopic Microsurgery for Lower or Upper Rectal Tumors. Published: 03/16/2010; Updated 04/1/2010.
  12. Gracia Solanas JA, Ramírez Rodríguez JM, Aguilella Diago V, Elía Guedea M, Martínez Díez M. A prospective study about functional and anatomic consequences of transanal endoscopic microsurgery. Rev Esp Enferm Dig. 2006 Apr; 98(4): 234-40. English, Spanish.
  13. Koebrugge B, Bosscha K, Ernst MF. Transanal endoscopic microsurgery for local excision of rectal lesions: is there a learning curve? Dig Surg 2009;26(5):372-7. Epub 2009 Nov 13.
  14. Lin GL, Meng WC, Lau PY, Qiu HZ, Yip AW. Local resection for early rectal tumours: Comparative study of transanal endoscopic microsurgery (TEM) versus posterior trans-sphincteric approach (Mason's operation). Asian J Surg. 2006 Oct; 29(4): 227-32. PMID: 17098653 [PubMed – indexed for MEDLINE].
  15. Maslekar S, Pillinger SH, Sharma A, Taylor A, Monson JR. Cost analysis of transanal endoscopic microsurgery for rectal tumours. Colorectal Dis. 2007 Mar; 9(3): 229-34. PMID: 17298620 [PubMed – indexed for MEDLINE].
  16. Medical Services Advisory Committee. Transanal endoscopic microsurgery. Canberra: Medical Services Advisory Committee (MSAC). 2004:137. Medical Services Advisory Committee (MSAC).
  17. Moore, JS, et al. Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colum Rectum 2008 Jul; 51(7): 1026-30; discussion 1030-1 Epub 2008 May 15. PMI: 18481147 [PubMed – indexed for Medline].
  18. National Cancer Institute (NCI). Rectal Cancer Treatment (PDQ®). Health Professional Version. Bethesda, MD: NCI; last modified 10/12/11.
  19. National Comprehensive Cancer Network (NCCN). Rectal Cancer. Clinical Practice Guidelines in Oncology – Rectal Cancer version 2.2012. Accessed 01/04/12.
  20. Papagrigoriadis S. Transanal endoscopic micro-surgery (TEMS) for the management of large or sessile rectal adenomas: a review of the technique and indications. Int Semin Surg Oncol. 2006 May 4; 3:13. PMID: 16674824 [PubMed].
  21. Patwardhan MB, Samsa GP, McCrory DC, Fisher DA, Mantyh CR, Morse MA, Prosnitz RG, Cline KE, Gray RN. Cancer Care Quality Measures: Diagnosis and Treatment of Colorectal Cancer. Evidence Report/Technology Assessment No. 138. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-02-0025.) AHRQ Publication No. 06-E002. Rockville, MD: Agency for Healthcare Research and Quality. May 2006.
  22. Platell C. Transanal endoscopic microsurgery. ANZ J Surg. 2009 Apr; 79(4): 275-80. PMID: 19432714 [PubMed – indexed for MEDLINE].
  23. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Position Statement on Endolumenal Therapies for Gastrointestinal Diseases, (11/08).
  24. Suzuki H, Furukawa K, Kan H, Tsuruta H, Matsumoto S, Akiya Y, Shinji S, Tajiri T. The role of transanal endoscopic microsurgery for rectal tumors. J Nippon Med Sch. 2005 Oct; 72(5): 278-84. PMID: 16247227 [PubMed – indexed for MEDLINE].
  25. The NCCN GUIDELINE Rectal Cancer Clinical Practice Guidelines in Oncology (Version 1.2009). © 2006 National Comprehensive Cancer Network, Inc. Available at: http://www.nccn.org. Accessed [Feb 4, 2009]. To view the most recent and complete version of the guideline, go online to www.nccn.org.
  26. Tjandra JJ, Kilkenny JW, Buie WD, Hyman N, Simmang C, Anthony T, Orsay C, Church J, Otchy D, Cohen J, Place R, Denstman F, Rakinic J, Moore R, Whiteford M; The Standards Practice Task Force; The American Society of Colon and Rectal Surgeons. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum. 2005 Mar; 48(3): 411-23.
  27. Zoller S, Joos A, Dinter D, Back W, Horisberger K, Post S, Palma P. Retrorectal tumors: excision by transanal endoscopic microsurgery. Rev Esp Enferm Dig. 2007 Sep; 99(9): 547-50. Review. PMID: 18052651 [PubMed – indexed for MEDLINE].

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/23/12.

GUIDELINE UPDATE INFORMATION:

03/15/09

New Medical Coverage Guideline.

08/15/09

Scheduled review; no change in position statement; references updated.

02/15/10

Revision consisting of change in position statement; references updated.

01/01/11

Annual HCPCS coding update: revised code descriptor for 0184T.

03/15/12

Scheduled review; position statement unchanged, references updated.

05/15/14

Revision; Program Exceptions section updated.

Date Printed: June 28, 2017: 11:52 PM