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MP 7.01.26 Infrared Coagulation for Hemorrhoids

Medical Policy
Section
Surgery
Original Policy Date
3/31/96
Last Review Status/Date
Reviewed by consensus/3:2003
Issue
3:2003
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Infrared coagulation, also called photocoagulation, is used to treat symptomatic first- and second-degree internal hemorrhoids. Pulses of infrared radiation are applied to the hemorrhoidal base through a hand-held applicator. These pulses produce a discreet area of necrosis, which heals to form a scar. This reduces or eliminates blood flow through the hemorrhoid, thereby shrinking it, and the mucosa becomes fixed to the underlying tissue. The procedure is easily performed in a physician’s office.

The diagnosis of internal and external hemorrhoids is made by inspection, digital examination, and direct vision through the anoscope and proctoscope. Whenever the internal hemorrhoidal plexus is enlarged, there is an associated increase in supporting mass, and the resultant venus swelling is called an internal hemorrhoid. When veins in the external hemorrhoidal plexus become enlarged, the resultant bluish mass is called an external hemorrhoid. External hemorrhoids require an incision because they are below the skin.


Policy

Infrared coagulation is considered medically necessary for persistently bleeding or painful first- and second-degree internal hemorrhoids.


Policy Guidelines

No applicable information


Benefit Application

BlueCard/National Account Issues

Payment may be considered for a maximum of four treatments within a six-month period.

Payment should not be considered for an anesthesiologist for postoperative pain consultation when performed on the same date of service as the epidural anesthesia.

Payment should not be provided to a surgeon assistant.


Rationale

A search of literature was completed through the MEDLINE database for the period of January 1984 through October 1995. The search strategy focused on references containing the following Medical Subject Heading:

– Infrared Coagulation

Research was limited to English-language journals on humans.

See also:

Technology Evaluation and Coverage 1987: p. 83

 

Codes

Number

Description

CPT  46934  Destruction of hemorrhoids, any method; internal 
ICD-9 Procedure  49.49  Other procedures on hemorrhoids 
ICD-9 Diagnosis  455.0 – 455.1  Internal hemorrhoids code range 
    Note: ICD-9 does not classify hemorrhoids by degrees. Below are narratives for each code. 
    455.0 Internal hemorrhoids without complication 
    455.1 Internal thromboses hemorrhoids 
HCPCS  No Code 
Type of Service  Surgery 
Place of Service  Outpatient
 
Physician’s Office
 


Index

Coagulation, infrared, of hemorrhoids
Hemorrhoids, infrared coagulation
Infrared coagulation of hemorrhoids


Policy History

Date Action Reason
3/31/96 Add to Surgery section New policy
8/18/00 Replace policy Archived policy
7/12/02 Replace policy Policy reviewed without literature review; new review date only
10/9/03 Replace policy Policy reviewed by consensus without literature review; no changes in policy; no further review scheduled


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