Transanal irrigation involves the introduction of water into the rectum using a gravity fed or pump system via a rectal catheter with an integral cone or balloon. Transanal irrigation results in an emptying of the lower bowel (rectum and distal sigmoid colon) and is used to prevent fecal incontinence (uncontrolled bowel movements) or to relieve and prevent constipation. Transanal irrigation may sometimes be included in a bowel management program for patients with neurogenic bowel dysfunction.

Note: Please see the following related documents for additional information:

• CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
• MED.00141 High-volume Colonic Irrigation
• SURG.00102 Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence

Clinical Indications

Medically Necessary:

Transanal irrigation is considered medically necessary when ALL the following criteria (A through D) are met:

1. The individual is at least 2 years of age; and
2. Diagnosed with one or more of the following conditions:
   1. Neurogenic bowel dysfunction; or
   2. Congenital disorder such as Hirschsprung disease or anorectal malformations; or
   3. Fecal incontinence; or
   4. Chronic constipation;
      and
3. Requires bowel management procedures that significantly impact the individual’s quality of life (for example, interferes with ability to fully participate in school or work); and
4. An adequate course of conservative medical management (including any combination of dietary modifications, bowel training, laxatives or constipation medications) has been unsuccessful or is contraindicated.

Not Medically Necessary:

Transanal irrigation is considered not medically necessary when the criteria above are not met.