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Date Printed: May 24, 2018: 11:42 AM

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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: 02/22/18

Revised: 03/15/18

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) is a minimally invasive approach to local excision of rectal lesions. It has been used in benign conditions such as large rectal polyps (that cannot be removed through a colonoscope), retrorectal masses, rectal strictures, rectal fistulae, pelvic abscesses, and in malignant conditions (eg, malignant polyps). Use of TEMS for resection of rectal cancers is more controversial. TEMS can avoid the morbidity and mortality associated with major rectal surgery, including the fecal incontinence related to stretching of the anal sphincter, and can be performed under general or regional anesthesia. The TEMS system has a specialized magnifying rectoscope with ports for insufflation, instrumentation, and irrigation. TEMS requires use of specialized equipment and several have been cleared for marketing by the U.S. Food and Drug Administration (FDA).

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 that cannot be removed using other means of local excision and 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. The evidence is insufficient to determine the effects of the technology on health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

0184T

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

ICD-10 Diagnoses Codes That Support Medical Necessity:

C20

Malignant neoplasm of rectum

D12.8

Benign neoplasm of rectum

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

DEFINITIONS:

None applicable.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. Al-Najami I, Rancinger CP, Larsen MK, et al. Transanal endoscopic microsurgery for advanced polyps and early cancers in the rectum-Long-term outcome: A STROBE compliant observational study. Medicine (Baltimore). Sep 2016;95(36):e4732.
  2. American Society for Gastrointestinal Endoscopy – Communication from ASGE Standards of Practice Committee; Guideline – Role of Endoscopic Ultrasound; Gastrointestinal Endoscopy; Vol 66, No 3: 2007.
  3. American Society of Clinical Oncology. Multi-modality approach in curative local treatment of early rectal carcinomas – 12 years Liverpool experience (2004).
  4. American Society of Clinical Oncology. Transanal Endoscopic Microsurgery for Rectal Lesions (1999).
  5. Blue Cross Blue Shield Association. Medical Policy Reference Manual 7.01.112 Transanal Endoscopic Microsurgery, 11/17.
  6. 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].
  7. ClinicalTrials.gov, Early Rectal Cancer: Endoscopic Submucosal Dissection or Transanal Endoscopic Microsurgery? (MUCEM); sponsored by Assistance Publique Hopitaux De Marseille, accessed 1/19/18.
  8. ClinicalTrials.gov, Prospective Randomized Clinical Trial for no Inferiority With Preoperative Chemoradiotherapy and Transanal Endoscopic Microsurgery (TEM) Versus Total Mesorectal Excision in T2-T3s N0, M0 Rectal Cancer; sponsored by Corporacion Parc Tauli, accessed 01/19/18.
  9. ClinicalTrials.gov, Transanal Endoscopic Microsurgery Versus Endoscopic Submucosal Dissection For Large Rectal Adenomas (TEMENDO); sponsored by European Association for Enoscopic Surgery, accessed 01/19/18.
  10. 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.
  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. First Coast Service Options Inc. (FCSO) Noncovered Services LCD (L33777); accessed at fcso.com.
  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. 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].
  15. Monson JR, Weiser MR, Buie WD, et al. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum. May 2013; 56(5):535-550; accessed at fascrs.org 01/19/18.
  16. 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].
  17. National Cancer Institute (NCI). Rectal Cancer Treatment PDQ). Healthcare Provider version. Updated 2017 April 27; accessed at cancer. Gov.
  18. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Rectal Cancer. Version 4.2017.
  19. 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].
  20. 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.
  21. Platell C. Transanal endoscopic microsurgery. ANZ J Surg. 2009 Apr; 79(4): 275-80. PMID: 19432714 [PubMed – indexed for MEDLINE].
  22. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Position Statement on Endolumenal Therapies for Gastrointestinal Diseases, (11/08).
  23. 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].

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/22/18.

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.

03/15/18

Review; Position statements maintained; description, coding, and references updated.

Date Printed: May 24, 2018: 11:42 AM