Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-91
Topic: Treatment of Gallstones
Effective Date: August 1, 2005
Issued Date: September 10, 2007
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

When reported, these therapies for the treatment of gallstones should be processed as follows:

  • Extracorporeal shock wave lithotripsy for treatment of gallbladder stones (S9034) is considered an eligible service when provided in conjunction with ursodiol therapy in a small subset of patients with symptomatic non-calcified single gallstones measuring 20 mm or less and who are not considered candidates for either open or laparoscopic cholecystectomy due to comorbidities, or who actively refuse a surgical option.
  • Endoscopic retrograde cholangiopancreatography (ERCP) for destruction lithotripsy (crushing) of stone (any method) (43265) is considered an eligible service.
  • Laparoscopic cholecystectomy by any method (e.g., laser or electrocautery) and laparoscopic cholecystectomy with cholangiography (47562 or 47563) are eligible for payment.
  • If an open cholecystectomy (47600 or 47605) is resorted to after the initiation of a laparoscopic procedure (47562 or 47563), reimbursement should be made for only the open cholecystectomy.

Description

Cholecystectomy is the surgical removal of the gallbladder and has been the most common treatment for gallstones. In the past few years, several non-surgical techniques and a less invasive laparoscopic procedure have been developed as alternative therapies for selected patients with cholelithiasis (i.e., gallstones).

Extracorporeal shock wave lithotripsy (ESWL) is a non-invasive procedure for disintegrating gallstones. The lithotripter uses high-energy shock to fragment gallstones. These shock waves are generated by the device and delivered to the patient. Ultrasound is used to locate the gallstones and to monitor fragmentation. Originally, ESWL was used in isolation for treatment of gallstones, but subsequently patients were additionally treated with ursodiol, a naturally occurring biliary acid that functions to further dissolve the fragmented stones. Patients are typically treated with ursodiol for a week before the procedure and after the procedure until stone clearance has been documented or up until 20 months.


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.

Procedure Codes

4326547562475634760047605S9034

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

References

National Blue Cross Blue Shield Association Medical Policy 7.01.35, Extracorporeal Shock Wave Lithotripsy for Gallstones, 04/2002

Treatment of Gallstones by Extracorporeal Shock Wave Lithotripsy, The American Journal of Gastroenterology, Vol. 97, No. 4, 04/2002

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[Version 001 of S-91]

Table Attachment

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Procedure Code Attachments

Diagnosis Codes

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.