BlueCross and BlueShield of Montana Medical Policy/Codes
Destruction of Hemorrhoids
Chapter: Surgery: Procedures
Current Effective Date: September 24, 2013
Original Effective Date: September 24, 2013
Publish Date: June 24, 2013
Revised Dates: This medical document is no longer scheduled for routine literature review and update.
Description

Hemorrhoids are swollen blood vessels in and around the anus and lower rectum that stretch under pressure, similar to varicose veins in the legs.  Swollen hemorrhoids may result from heredity, aging, and/or increased pressure from pregnancy, straining to move the bowel, or chronic constipation or diarrhea. 

Hemorrhoids are either inside the anus (internal) or under the skin around the anus (external).  The diagnosis of internal and/or external hemorrhoids is made by inspection, digital examination, and/or direct vision through the anoscope and proctoscope.  Internal hemorrhoids are a plexus of veins that represent a vascular cushion covered by loose areolar submucosal tissue of the lower rectum.  They occur in three primary positions: right anterior, right posterior, and left lateral.  Smaller hemorrhoids may occur between the primary locations.

Treatment is necessary only when hemorrhoids become enlarged and symptomatic.  First-degree internal hemorrhoids cause painless bright red rectal bleeding at the time of defecation.  At this early stage there is no prolapse, and anoscopic examination reveals enlarged hemorrhoids projecting into the lumen.  Second-degree internal hemorrhoids protrude through the anal canal on gentle straining, but spontaneously reduce.  Third-degree internal hemorrhoids protrude with straining and must be reduced manually after defecation.  Fixed protrusion defines fourth-degree internal hemorrhoids. 

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, has few complications, and results in less discomfort for the patient.  This is not a staged procedure, and the occasional need for a follow-up procedure during the 90-day postoperative period is considered to be a part of the routine follow-up care.  With appropriate treatment, all patients with symptomatic hemorrhoids should become asymptomatic.  A conservative approach should be used initially in nearly all cases. 

Electrocoagulation, monopolar coagulation, bipolar coagulation, microcurrent, direct-current, and galvanic current are electrocautery techniques that destroy hemorrhoids by thermal methods.  Coagulation causes the hemorrhoid tissue to harden and degenerate.  Cryotherapy is no longer recommended because of the long healing time and rate of complications.  

Doppler-guided hemorrhoidal artery ligation (DGHAL) is a new approach to surgical treatment of hemorrhoids.  DGHAL uses a proctoscope and Doppler ultrasound probe to identify and suture-ligate the terminal branches of the hemorrhoidal arteries.  It is minimally invasive, and is considered to be less painful than other surgical hemorrhoid treatments.

Policy

Prior authorization is recommended. To authorize, call Blue Cross and Blue Shield of Montana (BCBSMT) Customer Service at 1-800-447-7828 or fax your request to the Medical Review Department at 406-441-4624. A retrospective review is performed if services are not prior authorized.

Medically Necessary

BCBSMT may consider destruction of internal hemorrhoids by thermal methods medically necessary according to the following guidelines:

  • one treatment per 90 days per individual patient may be eligible for coverage; and
  • a total of three treatments per individual patient may be eligible for coverage.

Thermal methods of hemorrhoid destruction include, but are not limited to:

  • Laser and /or infrared coagulation (IRC);
  • Laser coagulation;
  • Electrocoagulation;
  • Bipolar (Bicap) coagulation;
  • Microcurrent and/or direct-current electrotherapy, (e.g., Ultroid, Keesey technique, etc.);
  • Monopolar coagulation;
  • Galvanic current;
  • Cryotherapy.

If the condition has not been resolved after three treatments, a different method of treatment is indicated.

IRC is not a multi-staged procedure.  When performed as a multi-staged procedure, IRC treatments outside the above guidelines are not eligible for additional coverage.

Occasionally, IRC follow-up treatments might be needed during the 90-day postoperative period. Additional treatments needed during the 90-day postoperative period do not count toward the limit of three treatments as they are follow-up care; they are not considered a separate procedure, and are not billed separately. 

Investigational

BCBSMT considers doppler-guided hemorrhoidal artery ligation (DGHAL) experimental, investigational and unproven.

Rationale for Benefit Administration

This medical policy was developed through consideration of peer reviewed medical literature, FDA approval status, accepted standards of medical practice in Montana, Technology Evaluation Center evaluations, and the concept of medical necessity. BCBSMT reserves the right to make exceptions to policy that benefit the member when advances in technology or new medical information become available.

The purpose of medical policy is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their medical judgment. BCBSMT recognizes the rapidly changing nature of technological development and welcomes provider feedback on all medical policies.

When using this policy to determine whether a service, supply or device will be covered, please note that member contract language will take precedence over medical policy when there is a conflict.

Rationale

Numerous clinical trials demonstrate that these thermal methods of hemorrhoid destruction may not only relieve symptoms with success rates comparable to alternatives (e.g., rubber band ligation, injection sclerotherapy), but may also offer several benefits, including that it can be performed in less than half the time, is associated with lower incidence of pain, and causes no major complications. 

A search of published literature in the MEDLINE database through October 2008 did not locate any studies that would alter the position of this policy.

2010 Update

A search for Doppler-guided hemorrhoidal artery ligation (DGHAL) in peer reviewed literature through November 2010 primarily identified small studies and case series.  Walega et al. reported a study they conducted to evaluate the clinical effectiveness and functional results of DGHAL as estimated by means of anorectal manometry.  Between 2000 and 2006 the DGHAL procedure was performed on 507 patients with II-IV degree hemorrhoids in two centers (Poland and Austria).  Three-hundred-eight patients were included in the initial phase of the study, designed to estimate the method's effectiveness.  During the second phase (199 patients) selected functional results were also assessed.  Patients were classified as having grade II (144), III (319), and IV (44) hemorrhoids.  There were no intra- and immediate-postoperative complications.  Good results were reported by 351 patients (69.2%), and were acceptable in a further 75 cases (4.8%). When the patients were grouped according to the stage of hemorrhoidal disease, 133 out of 144 patients (92.4%) with grade II and 272 out of 324 (84%) with grade III had very good or good results.  Only 18 out of 44 patients (41%) with grade IV were satisfied with the operation.  Fifty-nine patients after anorectal folds, fissure or anal canal polyp excision required analgesics for 1-2 days.  Apart from lower contraction amplitude and contraction speed after one month there were no differences in anorectal functional tests.  Based on their results, the authors concluded that DGHAL is a safe and effective method and may offer an important alternative to operative hemorrhoidectomy with no risk of postoperative stool incontinence, minimal postoperative pain, and early return of patients to their normal activities.  They also concluded that this is a fairly new procedure with a short-term follow-up, and that until 5-year observations of large, multicenter, randomized trials are published, they cannot recommend this method as a gold-standard procedure.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes
49.49, 455.0, 455.1, 455.2, 455.3, 455.4, 455.5, 455.6, 455.7, 455.8, 455.9
Procedural Codes: 46930, 0249T
References
  1. Leicester, R.J., Nicholls, R.J., et al.  Infrared Coagulation: A new treatment for hemorrhoids.  Disease of the Colon and Rectum (1981) 24:602-5.
  2. Ambrose, N.S., Hares, M.M., et al.  Prospective Randomized Comparison of Photocoagulation and Rubber Band Ligation in Treatment of Hemorrhoids.  British Medical Journal Medicine (1983) 286(6375):1389-91.
  3. Templeton, J.L., Spence, R.A.J., et al.  Comparison of Infrared Coagulation and Rubber Band Ligation for First and Second Degree Hemorrhoids: A Randomized Prospective Clinical Trial.  British Medical Journal (1983) 286(6375):1387-9.
  4. Ambrose, N.S., Morris, D., et al.  Randomized Trial of Photocoagulation or Injection Sclerotherapy for the Treatment of First- and Second-degree Hemorrhoids.  Diseases of the Colon and Rectum (1985) 28(4):238-40.
  5. Infrared Coagulation of Hemorrhoids. Chicago, Illinois: Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (1987 May):83-8.
  6. Walker, A.J., et al.  A prospective study of infrared coagulation, injection and rubber band ligation in the treatment of haemorrhoids.  International Journal of Colorectal Disease (1990 May) 5(2):113-6.
  7. Way, L.W.  Current Surgical Diagnosis and Treatment-9th Edition. Norwalk, Connecticut/San Mateo, California: Appleton & Lange (1991):683-5.
  8. Johanson, J.F. and A. Rimm.  Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy.  American Journal of Gastroenterology (1992 November) 87(11):1600-6.
  9. Practice Parameters for the Treatment of Hemorrhoids. American Society of Colon and Rectal Surgeons (1993 April) Available at <http://www.facrs.org>.  (Accessed – 1999 April 4).
  10. Infrared Coagulation for Hemorrhoids.  Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (1996 July 31) Surgery: 7.01.26.
  11. MacRae, H.M., and R.S. McLeod.  Comparison of hemorrhoidal treatments: a meta-analysis. Canadian Journal of Surgery (1997 February) 40(1):14-7.
  12. Medscape Hemorrhoids.  1999.  Prepared by National Institute of Diabetes and Digestive and Kidney Diseases (NIH publication number 94-3021: 1-4).  Available at <http://news.medscape.com.  (Accessed – 1999).
  13. Medscape Hemorrhoids.  1999. Prepared by National Digestive Diseases Information Clearinghouse (Hippocrates 10(2):1-4.  Available at <http://news.medscape.com>.  (Accessed 1999).            
  14. Linares, Santiago E., Gomez, Parra M., et al.  Effectiveness of hemorrhoidal treatment by rubber band ligation and infrared photocoagulation.  Revista Espanola de Enfermedades Digestivas (2001 April) 93(4):238-47.
  15. Gupta, P.J.  Infrared coagulation versus rubber band ligation in early stage of hemorrhoids.  Brazilian Journal of Medical and Biological Research (2003 October) 36(10):1433-9.
  16. Madoff, R.D. and J.W. Fleshman.  American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids.  Gastroenterology (2004) 126:1463-73.
  17. Marques, C.F., Nahas, S.C., et al.  Early results of the treatment of internal hemorrhoid disease by infrared coagulation and elastic banding: a prospective randomized cross-over trial.  Techniques in Coloproctology (2006 December) 10(4):312-7.
  18. Morin, N.  Hemorrhoids and fissure-in-ano.  American Society of Colon & Rectal Surgeons 2008.  Available at <www.fascrs.org> (Accessed – October 28, 2008).
  19. Albert, M.R., and L. Sergio.  S072- Minimally invasive hemorrhoidectomy: the hal
  20. ProcedureDepartment of Colorectal Surgery.  Florida Hospital, Orlando,FL (2007 April 21) Available at <www.sages.org> (accessed 2010 November 9).
  21. Walega, P., Scheyer, M., et al.  Two-center experience in the treatment of hemorrhoidal disease using Doppler-guided hemorrhoidal artery ligation: functional results after 1-year follow-up.  Surg Endosc. 2008 November; 22(11):2379-83. Epub 2008 July 12.
History
June 2013  New 2013 BCBSMT medical policy. 
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Destruction of Hemorrhoids