|MP 7.01.31||Continent Ileostomy and Urostomy|
|Original Policy Date
|Last Review Status/Date
Reviewed by consensus/3:2003
|Return to Medical Policy Index|
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.
The continent urostomy and continent ileostomy are surgical procedures that use a section of ileum to create an internal reservoir to hold urine or feces following cystectomy or colectomy. These procedures are sometimes referred to as the Kock continent urostomy and Kock continent ileostomy or Kock pouch. The internal reservoir allows a patient to void without wearing an external collecting bag. The patient intermittently drains the pouch by self-catheterization via a small stoma created in the abdominal wall.
A variant of the Kock ileostomy is the Barnett continent reservoir, which was designed to decrease the incidence of valve leakage. The main innovation is to configure the portion of ileum that serves as a valve in an isoperistaltic position, thus peristalsis moves toward the pouch, increasing its stability.
The Kock continent urostomy may be considered medically necessary following cystectomy.
The Kock continent ileostomy may be considered medically necessary in patients who have undergone coloproctectomy.
The Barnett continent reservoir may be considered medically necessary in patients who have undergone coloproctectomy.
The most common candidates for the Kock continent ileostomy and Barnett continent reservoir are those who have undergone a coloproctectomy for ulcerative colitis or familial polyposis.
No applicable information
The Barnett continent reservoir is a relatively new alternative to the Kock continent ileostomy. In a multicenter, uncontrolled case series, Mullen reported the results of 510 patients who underwent the procedure. (1) Of the 510 patients operated on, 470 (92.2%) had fully functioning pouches at least 1 year after initial surgery and, of these, 372 (79.1%) required no further pouch-related operations. Sixty patients (12.8%) required major subsequent surgical procedures. Complications included pouch failure, value slippage, and fistula formation. Centers participating in the uncontrolled case series include Century City Hospital in Los Angeles, Lutheran Medical Center in St. Louis, Palms of Pasadena Hospital in St. Petersburg, RHD Memorial Medical Center in Dallas, and West Boca Medical Center in Boca Raton, Florida.
1. Mullen P, Behrens D, Chalmers T et al. Barnett continent intestinal reservoir. Multicenter experience with an alternative to the Brooke ileostomy. Dis Colon Rectum 1995;38(6):573-82.
A search of literature was completed through the MEDLINE database for the period of January 1995 through December 1998. The search strategy focused on references containing the following words:
Technology Evaluation and Coverage 1988: p. 27
|CPT||44151||Colectomy, total abdominal, without proctectomy with continent ileostomy|
|44316||Continent ileostomy (Kock procedure)|
|50825||Continent diversion, including intestine anastomosis using any segment of small and/or large bowel (Kock pouch or Camey enterocystoplasty)|
|51596||Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder|
|ICD-9 Procedure||45.8||Total intra-abdominal colectomy|
|56.51||Formation of cutaneous ureter-ileostomy|
|57.79||Other total cystectomy|
|ICD-9 Diagnosis||No code|
|HCPCS||A5081||Continent device; plug for continent stoma|
|A5082||Continent device; catheter for continent stoma|
|Type of Service||Surgery|
|Place of Service||Inpatient|
Barnett continent reservoir
Continent urostomy and ileostomy
Ileostomy, kock continent
Kock continent urostomy and ileostomy
Urostomy, kock continent
|03/31/96||Add to Surgery section||New policy|
|03/15/99||Replace policy||Policy revised to include Barnett Continent Reservoir|
|04/15/02||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|