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Clinical Policy Bulletin:
Organ Prolapse: Selected Procedures
Number: 0858


Policy

Aetna considers laparoscopic suture rectopexymedically necessary in persons with rectal prolapse.

Aetna considers Lefort colpocleisis medically necessary for severe utero-vaginal prolapse in elderly patients and chronically ill persons who no longer desire coital function.

Aetna considers dynamic magnetic resonance imaging (MRI) medically necessary in persons with complex organ prolapse to supplement the physical examination.



Background

Pelvic organ prolapse is a relatively common condition in women that can have a significant impact on quality of life. Pelvic organ prolapse typically demonstrates multiple abnormalities and may involve the urethra (urethrocele), bladder (cystocele), vaginal vault, rectum (rectocele), and small bowel (enterocele). Symtpoms may include pain, pressure, urinary and fecal incontinence, constipation, urinary retention, and defecatory dysfunction. Total vaginal collapse occurs when the upper portion of the vagina loses its normal shape and sags or bulges down into the vaginal canal or outside of the vagina. It is usually caused by weakness of the pelvic and vaginal tissues and muscles and may occur alone or along with prolapse of other pelvic organs.  the bladder (cystocele), urethra (urethrocele), rectum (rectocele), or small bowel (enterocele).

Magnetic resonance imaging (MRI) uses a strong magnetic field, radio waves, and computers to produce two- or three- dimensional images of the inside of a patient's body. It is non-invasive and there is no ionizing radiation exposure to the patient. Dynamic MRI differs from standard MRI in that a large number of images are formed successively and rapidly, by continually updating or reacquiring image data. Based on the clinical evidence, dynamic magnetic resonance imaging (MRI) is an acceptable alternative modality in patients with complex organ prolapse to supplement the physical examination.

Rectal prolapse, or procidentia, is the abnormal protrusion of the rectal mucosa down to or through the anal opening. The main symptom is a protrusion of a reddish mass from the anal opening, especially following a bowel movement. The rectal mucosa is visible and may bleed slightly.

In a laparoscopic suture rectopexy the rectum is fixed to the presacral fascia with suture as opposed to mesh or an Ivalon sponge. Based on the long term clinical outcomes, laparoscopic suture rectopexy can be considered a treatment option for patients with rectal prolapse.

Vaginal prolapse or pelvic organ prolapse, occurs when the structures of the pelvis protrude into or outside of the vaginal canal. The pelvic organs are the bladder, rectum, or uterus. The term prolapse means slipping from the normal position. Pelvic organ prolapse is caused most commonly by pregnancy, labor, and childbirth. It also can be related to diseases that cause increased pressure in the abdomen, such as obesity, respiratory problems with a long-lasting (chronic) cough, constipation, and pelvic organ cancers. Pelvic organ prolapse can occur after hysterectomy for another gynecological health problem, such as endometriosis, dysfunctional uterine bleeding, or uterine fibroids. 

In the LeFort colpocleisis, anterior and posterior rectangular flaps of vaginal mucosa are removed, and the denuded areas are reapproximated with horizontal layers of interrupted absorbable sutures, leaving two small tunnels laterally for drainage. Based on the clinical evidence, Lefort colpocleisis should be used only when there is a very good reason not to perform one of the usual operations for prolapse. It is indicated for severe utero-vaginal prolapse in elderly patients and chronically ill patients who no longer desire coital function.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
Laparoscopic suture rectopexy - no specific code:
Dynamic magnetic resonance imaging (MRI) - no specific code:
57120
ICD-9 codes covered if selection criteria are met:
569.1 Rectal prolapse
618.00 - 618.9 Genital prolapse


The above policy is based on the following references:

Dynamic Magnetic Resonance Imaging

  1. Barbaric ZL et al. Magnetic resonance imaging of the perineum and pelvic floor. Top Magn Reson Imaging, 12(2): 83-92  2001.
  2. Boyadzhan L et al. Role of static and dynamic MR imaging in surgical pelvic floor dysfunction. Radiographics, 28(4): 949-67  2008. 
  3. Comiter CV at al. Grading pelvic prolapse and pelvic floor relaxation using dynamic magnetic resonance imaging. Urology, 54(3): 454-7  1999.
  4. Delamarre JB et al. Anterior rectocele: assessment with radiographic defecography, dynamic magnetic resonance imaging, and physical examination. Dis Colon Rectum, 37(3): 249-59  1994.
  5. Dohke M et al. Fast magnetic resonance imaging of pelvic organ prolapse. Tech Urol, 7(2): 133-8  2001.
  6. Feldman: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. Eighth Edition. 2006.
  7. Goodrich MA et al. Magnetic resonance imaging of pelvic floor relaxation: dynamic analysis and evaluation of patients before and after surgical repair. Obstet Gynecol, 82(6): 883-91  1993.
  8. Guffler H et al. Dynamic MRI after surgical repair for pelvic organ prolapse. J Comput Assist Tomogr, 26(5): 734-9  2002.
  9. Hodroff MA et al. Dynamic magnetic resonance imaging of the female pelvis: the relationship with the Pelvic Organ Prolapse quantification staging system. J Urol, 167(3): 1353-5  2002.
  10. Macura KJ. Magnetic resonance imaging of pelvic floor defects in women. Top Magn Reson Imaging, 17(6): 417-26  2006.
  11. Marinkovic SP; Stanton SL. Incontinence and voiding difficulties associated with prolapse. J Urol, 171(3): 1021-8  2004.
  12. Pannu HK. Dynamic MR imaging of female organ prolapse. Radiol Clin North Am, 41(2)  2003.
  13. Pannu HK et al. Dynamic MR imaging of pelvic organ prolapse: spectrum of abnormalities. Radiographics, 20(6): 1567-82  2000.
  14. Rodriguez LV; Raz S. Diagnostic imaging of pelvic floor dysfunction. Curr Opin Urol, 11(4): 423-8  2001.
  15. Savoye-Collet C et al. Radiologic evaluation of pelvic floor disorders. Gastroenterol Clin, 37(3) 2008.
  16. Singh K et al. Assessment and grading of pelvic organ prolapse by use of dynamic magnetic resonance imaging.  Am J Obstet Gynecol, 185(1): 71-7  2001.  
  17. Weidner AC; Low VHS. Imaging studies of the pelvic floor. Obst Gynecol Clin, 25(4) 1998.
  18. Wein: Campbel-Walsh Urology. Ninth Edition. 2007. tenth Edition. 2011.
  19. Yang A et al. Pelvic floor descent in women: dynamic evaluation with fast MR imaging and cinematic display. Radiology, 179(1): 25-33  1991.

Laparoscopic Suture Retropexy

  1. Akbari RP; Read TE. Laparoscopic rectal surgery: rectal cancer, pelvic pouch surgery, and rectal prolapse. Surgical Clinics of North America, Volume 86 Number 4  August 2006.
  2. Benoist  S et al. Functional results two years after laparoscopic rectopexy. American Journal of Surgery,
    Volume 182 (2)  August 2001.
  3. Byrne CM et al. Long-term functional outcomes after laparoscopic and open rectopexy for the treatment of rectal prolapse. Dis Colon Rectum, 51(11): 1597-604   2008.
  4. Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease. Seventh Edition. 2002. Eighth Edition. 2006.
  5. Felt-Bersma RJF et al. Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele. Gastroenterology Clinics, Volume 37, Issue 3  September 2008.
  6. Graf W et al. Laparoscopic suture rectopexy. Dis Colon Rectum, 38(2): 211-2  1995.
  7. Heah SM et al. Laparoscopic suture rectopexy without resection is effective treatment for full-thickness rectal prolapse. Dis Colon Rectum, 43(5): 638-43  2000.
  8. Hsu A; ; Brand MI; Saclarides TJ. Laparoscopic rectopexy without resection: a worthwhile treatment for rectal prolapse in patients without prior constipation. Am Surg, 01-SEP-2007; 73(9): 858-61.
  9. Lechaux D et al. Laparoscopic rectopexy for full-thickness rectal prolapse: a single-institution retrospective study evaluating surgical outcome. Surg Endosc, (): 0  2005.
  10. Madiba TE et al. Surgical management of rectal prolapse. Arch Surg, 140(1): 63-73  2005.
  11. McNevin MS et al. Overview of pelvic floor disorders. Surgical Clinics of North America, Volume 90, Issue 1. February 2010.
  12. Senagore AJ. Management of rectal prolapse: the role of laparoscopic approaches. Semin Laparosc Surg, 10(4): 197-202  2003.
  13. Tou S et al. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev, (4): CD001758   2008.
  14. Townsend: Sabiston Textbook of Surgery. Seventeenth Edition. 2004. Eighteenth Edition. 2007.

LeFort Colpocleisis

  1. Current Obstetric & Gynecologic Diagnosis & Treatment. Ninth Edition. 2003.
  2. Danforth’s Obstetrics and Gynecology. Eighth Edition. 1999.
  3. Ryan; Kistner’s Gynecology & Women’s Health. Seventh Edition. 1999.
  4. TeLinde’s Operative Gynecology. Eighth Edition. 1997.
  5. Vaginal Surgery. Fourth Edition. 1996.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna 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 Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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