A4563 — Rectal control system for vaginal insertion, for long term use, includes pump and all supplies and accessories, any type each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For ACE/appendicostomy/INA: surgical notes and anatomy documentation (eg, confirmation appendix absent or previously used for Mitrofanoff when INA is considered).
- Records of prior pelvic or anorectal surgeries (eg, prior prolapse surgery) and anatomic factors that may affect device fitting (eg, vaginal length) — relevant to VBC candidacy and likelihood of successful fitting.
- Pre- and post-procedure assessments of outcomes and complications (eg, FI-QOL, St Mark's/Vaizey scores, follow-up notes documenting stomal problems, catheterization difficulties, leakage, need for revision), as used in the cited studies — inferred documentation to support clinical necessity and outcomes.
- For Acticon Neosphincter: documentation of age ≥ 18 years and that the patient has failed or is not a candidate for medical interventions or surgical sphincter repair (as specified).
Key Coverage Criteria
- An anal sphincter repair for members with severe fecal incontinence who have failed, or are not candidates for, medical interventions (e.g., biofeedback, dietary management, pharmacotherapy, strengthening exercises).
- Diagnostic tests considered medically necessary for fecal incontinence: Anorectal manometry (see CPB 0616 - Gastrointestinal Manometry), Anorectal ultrasonography, Rectal sensory testing.
- Conservative treatments considered medically necessary for fecal incontinence: Biofeedback (see CPB 0132 - Biofeedback), Bowel training, Defecation programs, Diet modification, Pharmacotherapy.
- Malone described a surgically-created appendicostomy for delivering anterograde colonic enemas in children with constipation or FI.
- Enemas can be delivered via a button cecostomy device created by a colonoscopy and percutaneous technique.
- Colostomy for members with severe fecal incontinence who have failed, or are not candidates for, medical interventions (e.g., biofeedback, dietary management, pharmacotherapy, strengthening exercises) or surgical sphincter repair (e.g., post-anal repair, sphincteroplasty, or total pelvic floor repair).
1 Active Policy
AETNA-CPB-0611 — Fecal Incontinence
Related Codes
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