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| Section: |
Surgery |
| Number: |
S-170 |
| Topic: |
Infrared Coagulation of Hemorrhoids |
| Effective Date: |
January 1, 2009 |
| Issued Date: |
January 5, 2009 |
| Date Last Reviewed: |
11/2008 |
General Policy Guidelines
Indications and Limitations of Coverage
Infrared coagulation of hemorrhoids (46930) is considered medically necessary for persistently bleeding or painful first and second degree internal hemorrhoids (455.0, 455.1, and 455.2). Infrared coagulation of hemorrhoids reported for indications other than those listed above should be denied as not medically necessary, and therefore, not covered. A participating, preferred, or network provider cannot bill the member for the denied service.
Procedure code 46930 should be reported only once per operative session regardless of the number of hemorrhoids treated.
Payment may be made for a maximum of four treatments within a six-month period.
Description
Infrared coagulation (IRC), 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. |
- NOTE:
- This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
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Procedure Codes
Traditional Guidelines
FEP Guidelines
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program. |
PPO Guidelines
Managed Care POS Guidelines
Publications
References
National Blue Cross Blue Shield Association Medical Policy 7.01.26, Infrared Coagulation of Hemorrhoids, 10/2003
American Gastroenterological Association Technical Review on the Diagnosis and Treatment of Hemorrhoids, Gastroenterology, Volume 126, No. 5, 05/2004 |
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Table Attachment
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Procedure Code Attachment
Glossary
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
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