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This procedure has been available for nearly 20 years in Europe but has not been used widely in the United States. Two reasons for this slow diffusion are the steep learning curve for the procedure and the limited indications. As examples, most rectal polyps can be removed endoscopically and many rectal cancers need a wide excision and are thus not amenable to local resection.

TEMS has potential use when traditional transanal approaches are not possible. TEMS has been used in benign conditions such as large rectal polyps (that cannot be removed through a colonoscope), retrorectal masses, rectal strictures, rectal fistulae, pelvic abscesses, and in malignant conditions such as malignant polyps, T1 –T2 rectal cancer, and palliative excision of T3 rectal cancers. When these lesions cannot be removed through the anus, an anterior abdominal approach or abdominoperineal resection would often be used. TEMS is viewed as an alternative in these cases.

As noted above, this procedure requires use of specialized equipment. The Transanal Endoscopic Microsurgery (TEM) Combination System and Instrument Set (Richard Wolf Medical Instruments Corp) received 510(k) marketing clearance from the U.S. Food and Drug Administration in 2001.

Transanal endoscopic microsurgery may be considered medically necessary for treatment of clinical stage T1 rectal adenocarcinomas that cannot be removed using other means of local excision and that meet all of the following criteria:

• Located in the middle or upper part of the rectum, AND
• Well or moderately differentiated (G1 or G2) by biopsy, AND
• Without lymphadenopathy, AND
• Less than 1/3 circumference of the rectum

Transanal endoscopic microsurgery is considered investigational for treatment of rectal tumors that do not meet the criteria noted above.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

3/27/2008: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)

05/28/2010: Policy statement section revised to include indications that may be considered medically necessary for transanal endoscopic microsurgery; FEP verbiage was added to the Policy Exceptions sections; Code Reference section revised to move CPT Code 0184T from non-covered to covered codes table and added the following ICD-9 Diagnosis codes to covered codes table: 154.1, 209.17, 209.57, 211.4 and 230.4.  

12/28/2010:  Policy reviewed; no changes.

01/17/2012:  Policy reviewed; no changes.

03/13/2013:  Policy reviewed; no changes.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

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