Medical Policy Bulletin

Section:	Surgery
Number:	S-96
Topic:	Laparoscopic Surgery
Effective Date:	August 1, 2005
Issued Date:	August 1, 2005
Date Last Reviewed:	06/2005

General Policy Guidelines

Indications and Limitations of Coverage

Laparoscopic surgeries (e.g., laparoscopic appendectomy, splenectomy, intestinal resection, etc.) are eligible for reimbursement. In most instances, reimbursement should equal the reimbursement level of the corresponding open procedures.

Laparoscopic procedures that do not have a specific procedure code and are not addressed on a medical policy bulletin will be given individual consideration.

In addition, when an open procedure is resorted to after the initiation of a laparoscopic procedure, payment should be made only for the open procedure.

Keyhole vesicourethropexy is eligible for reimbursement under procedure codes 51990, 51992.

NOTE:

See Medical Policy Bulletin G-24 (Obesity) for guidelines on the surgical treatment of obesity.

Also see Medical Policy Bulletin S-91 (Treatment of Gallstones).

Description

Laparoscopic surgery is a minimally invasive alternative approach to certain conventional (incisional) surgeries. In laparoscopic surgery, a viewing scope outfitted with a lighting system and a video camera is inserted through a minute incision. The video camera sends a magnified image to TV monitors positioned near the operating table. The surgeon watches the TV screen and performs the operation by manipulating special scissors, pincers, and other tools through several more strategically placed holes.

Keyhole Vesicourethropexy
Although not a true laparoscopic procedure, keyhole vesicourethropexy is a minimally invasive bladder suspension procedure used for the treatment of stress urinary incontinence. The procedure is a modification of the Marshall Marchetti procedure performed through a small "keyhole" suprapubic incision, utilizing microsurgical techniques to suspend the bladder.

Procedure Codes

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

06/1993, Laparoscopic surgery

References

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Glossary

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.