Medical Policy
Effective Date:12/01/2011 Title:Transanal Enoscopic Microsurgery (TEMS)
Revision Date:10/01/2015 Document:BI326:00
CPT Code(s):0184T
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Transanal endoscopic microsurgery (TEMS) involves the use of specialized equipment including an operating proctoscope, insufflation, and magnified stereoscopic views for resection of rectal tumors.  This technique is covered for patients meeting specific criteria.
Medical Statement

Transanal endoscopic microsurgery (TEMS) is covered for the following conditions:

  1. Rectal adenomas, including recurrent adenomas, that cannot be removed using other means of local excision, or
  2. T1 rectal adenocarcinomas that cannot be removed using other means of local excision and also meet all of the following criteria:
        • Located in the middle or upper part of the rectum
        • Well or moderately differentiated (G1 or G2)
        • Without lymphadenopathy or microscopic angiolymphatic invasion
        • Less than 1/3 the circumference of the rectum.

Codes Used In This BI:

0184T, Excision of rectal tumor, transanal endoscopic microsurgical approach
Limits

TEMS is considered experimental for all other indications.
Reference

Cataldo PA. (2006) Transanal microscopic microsurgery. Surg Clin North Am, 2006; 86:915-25.

Doornebosch PG, Tollenaar RA, De Graaf EJ. (2009) is the increasing role of transanal endoscopic microsurgery in curation for T1 rectal cancer justified? A systematic review. Acta Oncol 2009; 48:343-353.

Lezoche E, Guerrieri M, et al. (2005) Transanal endoscopic versus total mesorectal laparoscopic resections of T2-N0 low rectal cancers after neoadjuvant treatment: a prospective randomized trial with a 3-years minimum follow-up period. Surg Endosc, 2005; 19:751-6.

Lezoche G, Baldarelli M, et al. (2007) A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc, 2007; [epub ahead of print].

Lezoche G, Baldarelli M, Guerrieri M et al.(2008) A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc 2008; 22:352-358.

Maslekar S, Pillinger SH, Monson JR. (2007) Transanal endoscopic microsurgery for carcinoma of the rectum. Surg Endosc, 2007; 21:97-102.

Middleton PF, Sutherland LM, Maddern GJ. (2005) Transanal endoscopic microsurgery: a systematic review. Dis Colon Rectum, 2005; 48:270-84.

Moore JS, Cataldo PA, Osler T et al. (2008) Transanal endoscopic microsurgery is more effective than traditional transanal excision for resection of rectal masses. Dis Colon Rectum 2008; 5:1026-1030.

NCCN (National Comprehensive Cancer Network). 2009. Practice Guidelines in Oncology. Rectal Cancer. Accessible at http://www.nccn.org/professionals/physician_gls/PDF/rectal.pdf, accessed 15 Oct 2009.

Transanal Endoscopic Microsurgery for rectal cancer. Hayes Directory, Dec 31, 2007.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.