L30862-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Destruction of Internal Hemorrhoid(s)

by Infrared Coagulation (IRC) (L30862)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L30862

LCD Title Destruction of Internal Hemorrhoid(s) by Infrared Coagulation (IRC)

Contractor's Determination Number 46930

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 06/07/2010

Original Determination Ending Date

Revision Effective Date

For services performed on or after 06/07/2010

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represent quotation from one or more of the following CMS sources: CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40

Indications and Limitations of Coverage and/or Medical Necessity

Hemorrhoids are vascular cushions within the anal canal, usually found in three main locations: left lateral, right anterior, and right posterior portions. They lie beneath the epithelial lining of the anal canal and consist of direct arteriovenous communications, mainly between the terminal branches of the superior rectal and superior hemorrhoidal arteries, and, to a lesser extent, between branches originating from the inferior and middle hemorrhoidal arteries and the surrounding connective tissue.

Hemorrhoids are classified according to their origin; the dentate line (pectinate line) serves as an anatomic- histologic border. External hemorrhoids originate distal to the dentate line, arising from the inferior hemorrhoidal plexus, and are lined with modified squamous epithelium, which is richly innervated with somatic pain fibers (delta type, unmyelinated). Internal hemorrhoids originate proximal to the dentate line, arising from the superior hemorrhoidal plexus, and are covered with mucosa. Internal hemorrhoids do not have cutaneous innervation and can therefore be destroyed without anesthetic. Internal hemorrhoids usually become symptomatic only when they prolapse, become ulcerated, bleed, or thrombose.

Internal hemorrhoids are further classified into four stages according to the extent of prolapse, as follows:

• Stage I - Bleed without prolapse

• Stage II - Prolapse with Valsalva with spontaneous reduction, with or without bleeding

• Stage III - Prolapse with Valsalva requiring manual reduction, with or without bleeding

• Stage IV - Irreducible prolapsed and manual reduction is ineffective

The initial conservative treatment for symptomatic hemorrhoids should include dietary management consisting of adequate fluid and fiber intake to relieve constipation and eliminate straining at defectation. At least six weeks may be required for significant improvement. Conservative treatment should continue even if a procedure is required.

Infrared coagulation (IRC) is one of several non-surgical therapies for the treatment of internal hemorrhoids without the need for anesthesia. Infrared coagulation involves direct application of infrared waves which penetrates the tissue and converts to heat, promoting coagulation of vessels and fixation of the hemorrhoidal tissue. The amount of tissue destruction depends on the intensity and duration of the application. It is recommended that the infrared probe be applied for 1.5 seconds to the apex of each internal hemorrhoid and be repeated three times on each hemorrhoid. Infrared coagulation involves direct application of infrared waves resulting in protein necrosis, and is considered useful only in the treatment of Stage 1 and Stage II hemorrhoids, without significant prolapse. IRC is associated with high rates of recurrence when substantial prolapse is present. Multiple (2-6) hemorrhoids can be treated at one time using IRC.

Indications

FCSO Medicare will consider infrared coagulation (IRC) medically reasonable and necessary for the treatment of symptomatic Stage I or Stage II internal hemorrhoids that have not responded to conservative treatment.

Limitations

IRC is considered useful only in the treatment of Stage 1 and Stage II internal hemorrhoids, without significant prolapse.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

46930 DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)

ICD-9 Codes that Support Medical Necessity

455.1 INTERNAL HEMORRHOIDS WITHOUT COMPLICATION

455.2 INTERNAL THROMBOSED HEMORRHOIDS

455.3 INTERNAL HEMORRHOIDS WITH OTHER COMPLICATION

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the performing provider should include the following, and made available to FCSO Medicare upon request:

• A problem-specific history and physical examination, which should include:

- Information regarding any prior treatments for hemorrhoids and patient’s response.

- The type of conservative treatments utilized and patient’s response.

- The length of time allowed for the resolution of symptoms.

• Results of the physical examination, which should typically include visual inspection of the anus, digital rectal examination and anoscopy.

- Patients with rectal bleeding usually undergo sigmoidoscopy.

- The proximal colon should be evaluated by colonoscopy or air-contrast barium enema to assess bleeding that is not typical of hemorrhoids (e.g., dark blood or blood mixed in the feces), guaiac-positive stools, or anemia. The individual patient’s risk factors for colorectal cancer (age, family history, or personal history of polyps) should also be considered when deciding on the extent of colonic evaluation.

• The classification (stage) of the hemorrhoidal disease:

- Stage I - Bleed without prolapse

- Stage II - Prolapse with Valsalva with spontaneous reduction, with or without bleeding

- Stage III - Prolapse with Valsalva requiring manual reduction, with or without bleeding

- Stage IV - Irreducible prolapsed and manual reduction is ineffective

Appendices

Utilization Guidelines Only one unit of service should be submitted per patient per global period (90 days), regardless of the number of sites treated by infrared coagulation. Any subsequent or re-treatment during the 90- day global period should NOT be separately billed.

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision

American Gastroenterological Association medical position statement: Diagnosis and treatment of hemorrhoids. (2004). Gastroenterology, 126(5), 1461-1462. Retrieved December 10, 2009 from www.guideline.gov.

Cataldo, et al. The Standards Practice Task Force. The American Society of Colon and Rectal Surgeons. (2005). Practice parameters for the management of hemorrhoids (revised). Dis Colon Rectum, 48, 189-194. Retrieved December 10, 2009 from www.fascrs.org.

Kaidar-Person, O., Person, B., & Wexner, S. (2007). Hemorrhoidal Disease: A comprehensive review. J Am Coll Surg, 204(1), 102-117. Retrieved December 11, 2009 from www.mdconsult.com.

Society for Surgery of the Alimentary Tract: Surgical management of hemorrhoids. (2008). Retrieved December 10, 2009 from www.ssat.com.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from the Florida Gastroenterologic Society and the Florida Chapter of the American College of Surgeons.

Florida Contractor Advisory Committee Meeting held on February 13, 2010.

Puerto Rico/U.S. Virgin Islands Contractor Advisory Meeting held on February 25, 2010.

Start Date of Comment Period 02/04/2010

End Date of Comment Period 03/20/2010

Start Date of Notice Period 04/23/2010

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:02/04/2010

Start Date of Notice Period:04/23/2010 Original Effective Date:06/07/2010

LCR B2010 - 041

April 2010 Update

Reason for Change