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Fecal Incontinence Management

» Summary» Procedure Codes
» Description» Selected References
» Prior Approval» Policy History
» Policy
 

Medical Policy: 02.01.51 
Original Effective Date: September 2013 
Reviewed: August 2014 
Revised: August 2014 


Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.


Description: 

Fecal incontinence refers to the involuntary loss of gas or liquid stool (called minor incontinence) or the involuntary loss of solid stool (called major incontinence). Continence requires the normal function of both the lower digestive tract and the nervous system. The anal sphincters, along with the pelvic muscles that surround the end of the digestive tract, ensure controlled movement of digestive tract contents. There are many possible causes of fecal incontinence; in most cases, incontinence results from some combination of damage to the anal sphincters, neurologic causes, decreased distensibility of the rectum, fecal impaction and diarrhea. Treatment includes behavior changes, medication, the use of bulking substances, treatment of impaction, nerve stimulation and surgery.

 

Bulking Agents
Several agents (Durasphere, silicone biomaterial, etc) have been studied for the treatment of fecal incontinence. To date, only one bulking agent has been approved by the FDA for treating fecal incontinence. This is a formulation of non-animal stabilized hyaluronic acid/dextranomer in stabilized hyaluronic acid (NASHA Dx) and is marketed by Q-Med as Solesta. Solesta is a sterile gel that is injected into the anal. It is composed of naturally made materials, dextranomer and sodium hyaluronate. Solesta is classified as a medical device (injectable bulking agent) and not a drug.

 

Transanal Radiofrequency Therapy
Radiofrequency (RF) energy has been investigated as a minimally invasive treatment of fecal incontinence, a procedure referred to as the Secca procedure. In this outpatient procedure using conscious sedation, RF energy is delivered to the sphincteric complex of the anal canal to create discrete thermal lesions. Over several months, these lesions heal and the tissue contracts, changing the tone of the tissue.

 

Perianal Electrical Nerve Stimulation
Electrical stimulation with a non-implantable stimulator is delivered generally by anal probes connected to an external pulse generator. The electrical stimulation is controlled via a probe wired to a device. A variation in the amplitude and frequency of the electrical pulse is used to mimic and stimulate the different physiologic mechanisms of the voiding response, depending on the type of etiology of incontinence.

 

Posterior tibial nerve stimulation (PTNS)
The procedure for PTNS consists of the insertion of a needle above the medial malleolus into the posterior tibial nerve followed by the application of low voltage (10mA, 1–10 Hz frequency) electrical stimulation that produces sensory and motor responses (i.e., a tickling sensation and plantar flexion or fanning of all toes). Noninvasive PTNS has also been delivered with surface electrodes.

 

 

Note: see the related policy, number 02.01.04, Anorectal Biofeedback

 


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Prior Approval: 

 

Not applicable.


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Policy: 

  1. Transanal radiofrequency therapy for the treatment of fecal incontinence (also known as the Secca procedure) is considered investigational because its effectiveness has not been established.
  2. Perianal electrical stimulation is considered investigational because its effectiveness has not been established.
  3. The use of injectable bulking agents (Solesta, autologous myoblast cells, collagen, etc) for the treatment of fecal incontinence is considered investigational because their effectiveness has not been established.
  4. Posterior tibial nerve stimulation for fecal incontinence is considered investigational.

The above treatments for fecal incontinence lack demonstration of efficacy and long term effects at this time. There remains a lack of information regarding the predictive factors for successful treatment selection at this time.





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Procedure Codes and Billing Guidelines: 

  • To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
  • L8605 Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 ml, includes shipping and necessary supplies

  • 0288T Anoscopy, with delivery of thermal energy to the muscle of the anal canal (eg, for fecal incontinence)
  • 64566  Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming


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Selected References: 

  • National Institute for Health and Clinical Excellence (NICE). Endoscopic radiofrequency therapy of the anal sphincter for faecal incontinence (2011). Last accessed September 2013.

  • Ruiz D, Pinto RA, Hull TL et al. Does the radiofrequency procedure for fecal incontinence improve quality of life and incontinence at 1-year follow-up? Dis Colon Rectum 2010; 53(7):1041-6.

  • Dehli T, Stordahl A, Vatten LJ et al. Sphincter training or anal injections of dextranomer for treatment of anal incontinence: a randomized trial. Scand J Gastroenterol 2013

  • Leung FW. Treatment of fecal incontinence - review of observational studies (OS) and randomized controlled trials (RCT) related to injection of bulking agent into peri-anal tissue. J Interv Gastroenterol 2011; 1(4):202-06

  • Maeda Y, Laurberg S, Norton C. Perianal injectable bulking agents as treatment for faecal incontinence in adults. Cochrane Database Syst Rev. 2013 Feb 28;2:CD007959

  • National Institute of Health and Clinical Excellence (NICE). Percutaneous tibial nerve stimulation for faecal incontinence (2011). Available online at: www.nice.org.

  • Hosker G, Norton C, Brazzelli M. Electrical stimulation for faecal incontinence in adults. Cochrane Database Syst Rev. 2000;(2).

  • Satish S, Rao M. Diagnosis and management of fecal incontinence. Practice Guidelines. American Journal of Gastroenterology 2004; doi:10.1111/j.1572-0241.2004.40105.x


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Policy History: 

Date                                        Reason                               Action

September 2013                                                                 New policy

August 2014                            Annual review                      Policy revised


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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.

 
Contact Information
New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
  Wellmark Blue Cross and Blue Shield
  Medical Policy Analyst
  P.O. Box 9232
  Des Moines, IA 50306-9232
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