About this policy
Jurisdiction: JM Part B. States: North Carolina, South Carolina, Virginia, West Virginia. Type: Active LCD
Coverage indications
Transanal endoscopic surgery (TES) may be considered medically necessary for treatment of rectal adenomas, including recurrent adenomas that cannot be removed using other means of local excision. TES may be considered medically necessary for treatment of clinical stage T1 rectal adenocarcinomas that cannot be removed using other means of local excision and that meet all of the following criteria: Located within 8 cm of the anal verge Less than 3 cm in size Well-to-moderately differentiated (G1 or G2) by biopsy Without lymphadenopathy Less than 30% of the circumference of the rectum TES may be considered medically necessary for treatment of rectal carcinoid tumors that cannot be removed using other means of local excision and that meet all of the following criteria: Located within 8 cm of the anal verge Less than 2 cm in size No radiologic evidence of metastasis Less than 30% of the circumference of the rectum TES is considered investigational for treatment of rectal tumors that do not meet the criteria noted. Credentialing and Accreditation Standards Optimal outcomes of TES procedures depend on the knowledge, skill and experience of the provider. Services will be considered medically reasonable and necessary only if performed by appropriately trained providers. FDA Indications Transanal Endoscopic microsurgery (TEM) combination system and instrument set. 510K Summary: K000180. GelPOINT Path Transanal Access Platform. 510K Summary: K133393 . GelPOINT Path Transanal Access Platform. 510K Summary: K171701 .
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.