200 Form

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Medical Policy Transanal Endoscopic Microsurgery Table of Contents • Policy: Commercial • Description • Information Pertaining to All Policies
• Authorization Information • Policy History

• Coding Information • References

Policy Number: 200 BCBSA Reference Number: 7.01.112 (For Plan internal use only) NCD/LCD: N/A Related Policies
None Policy
Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Transanal endoscopic microsurgery for treatment of rectal adenomas, including recurrent adenomas that cannot be removed using other means of local excision may be considered MEDICALLY NECESSARY.

Transanal endoscopic microsurgery 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 may be considered MEDICALLY NECESSARY: • Located in the middle or upper part of the rectum, AND • Well or moderately differentiated (G1 or G2) by biopsy, AND
• Without lymphadenopathy, AND • Less than 1/3 the circumference of the rectum.

Transanal endoscopic microsurgery for treatment of rectal tumors that do not meet the above criteria is INVESTIGATIONAL.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient

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Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required. Medicare PPO BlueSM Prior authorization is not required. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: CPT Codes CPT codes:

Code Description 0184T Excision of rectal tumor, transanal endoscopic microsurgical approach (i.e., TEMS) The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT code above if medical necessity criteria are met: ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description C20 Malignant neoplasm of rectum D01.2 Carcinoma in situ of rectum D12.8 Benign neoplasm of rectum

Description Transanal Endoscopic Microsurgery 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 TEM for resection of rectal cancers is more controversial. TEM 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 TEM system has a specialized magnifying rectoscope with ports for insufflation, instrumentation, and irrigation. This procedure has been available in Europe but has not been widely used in the U.S. Two reasons for this slow adoption are the steep learning curve for the procedure and the limited indications. For example, most rectal polyps can be removed endoscopically, and many rectal cancers need a wide excision and are thus not amenable to local resection. Other Treatment Options The most common treatment for rectal cancer is surgery; the technique chosen will depend on several factors. The size and location of the tumor, evidence of local or distal spread, and an individual's

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characteristics and goals are all attributes that will affect the treatment approach. Open, wide resections have the highest cure rate but may also have significant adverse events. Most Individuals find the potential adverse events of lifelong colostomy and/or bowel, bladder, or sexual dysfunction acceptable in the face of a terminal illness. Laparoscopic-assisted surgery, with lymph node dissection as indicated, is technically difficult in the pelvic region but is being investigated as a less invasive alternative to open resection. Local excision alone does not offer the opportunity for lymph node biopsy and therefore has been reserved for patients in whom the likelihood of cancerous extension is small. Local excision can occur under direct visualization in rectal tumors within 10 cm of the anal verge. TEM extends local excision ability to the proximal rectosigmoid junction. Adenomas, small carcinoid tumors, and nonmalignant conditions (eg, strictures, abscesses) are amenable to local excision by either method. The use of local excision in rectal adenocarcinoma is an area of much interest and may be most appropriate in small tumors (<4 cm) confined to the submucosa (T1, as defined by the tumor, node, and metastasis staging system). Presurgical clinical staging, however, may miss up to 15% of regional lymph node spread. During local excision, the excised specimen should be examined by a pathologist. If adverse features such as high-grade pathology or unclear margins are observed, the procedure can be converted to a wider resection. Despite this increased risk of local recurrence, local excision may be an informed alternative for patients. TEM permits local excision beyond the reach of direct visualization equipment.

Summary
Transanal endoscopic microsurgery (TEM) is a minimally invasive approach for local excision of rectal lesions that cannot be directly visualized. It is an alternative to open or laparoscopic excision and has been studied in the treatment of both benign and malignant conditions of the rectum. For individuals who have rectal adenoma(s) who receive transanal endoscopic microsurgery (TEM), the evidence includes a few nonrandomized comparative studies and numerous single-arm case series. Relevant outcomes are overall survival (OS), functional outcomes, health status measures, quality of life (QOL), and treatment-related morbidity. The evidence supports conclusions that the removal of polyps by TEM is associated with low postoperative complication rates and low-risk of recurrence. However, due to the low quality of the evidence base, no conclusions can be made on the comparative efficacy of TEM and standard procedures. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have early rectal adenocarcinoma who receive TEM, the evidence includes 2 small randomized controlled trials (RCTs), a few nonrandomized comparative studies, numerous single-arm case series, and systematic reviews of these studies. Relevant outcomes are OS, functional outcomes, health status measures, QOL, and treatment-related morbidity. The evidence supports conclusions that TEM is associated with fewer postoperative complications but higher local recurrence rates and possibly higher rates of metastatic disease. One systematic review indicates improved OS with radical surgery compared with TEM; however, the majority of systematic reviews did not demonstrate significant differences in OS. However, due to the low quality of the evidence base, these conclusions lack certainty. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 1/2026 Annual policy review. References updated. Policy statements unchanged. 1/2025 Annual policy review. References updated. Policy statements unchanged. 1/2024 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2023 PA information section clarified to include Medicare.

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1/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
12/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 2/2018 Clarified coding information. 12/2016 Annual policy review. New references added. 11/2015 Annual policy review. New references added.Clarified coding information. 6/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015. 12/2013 Annual policy review. New references added. 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. No changes to policy statements.
10/2011 Reviewed - Medical Policy Group - GI, Nutrition and Organ Transplantation. No changes to policy statements. 11/2010 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 7/1/2010 Medical Policy #200 created.

Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

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27. van Heinsbergen M, Leijtens JW, Slooter GD, et al. Quality of Life and Bowel Dysfunction after Transanal Endoscopic Microsurgery for Rectal Cancer: One Third of Patients Experience Major Low Anterior Resection Syndrome. Dig Surg. 2020; 37(1): 39-46. PMID 31185474
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