CurrentAetnaPolicy 0718

Defecography

Defines Aetna's medical necessity and investigational positions for defecography and MR defecography, applicable indications (chronic constipation with negative/inconclusive anorectal manometry and rectal balloon expulsion) and lists related CPT/HCPCS/ICD-10 codes and background evidence. This is part 1 of 2.

Policy Summary

PayerAetna

PolicyDefecography

Policy CodePolicy 0718

Change TypeNo material change

Effective DateOct 18, 2005

Next Review DateAug 8, 2024

Key ActionDefecography should be performed only after anorectal manometry and rectal balloon expulsion have been performed and found negative or inconclusive; providers must document these prior test results and clinical suspicion (anterior rectocele, enterocele, inappropriate puborectalis contraction, or pelvic organ prolapse) to meet medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — has_material_change=false.

4Specific suspected causes required for coverage

3Investigational categories listed (examples)

2005-2023Policy effective to last review span (years)

2024-08-08Next review

Coverage Summary

Scope: Defines Aetna's positions on defecography and MR defecography for evaluation of anorectal function in members with chronic constipation and related pelvic floor disorders. Effective date: 2005-10-18; Last review: 2023-09-21; Next review: 2024-08-08.

Policy overview: Aetna considers fluoroscopic/evacuation proctography (defecography) medically necessary when ALL of the following are met: documented chronic constipation (per the policy definition) AND anorectal manometry and rectal balloon expulsion testing are negative or inconclusive AND there is clinical suspicion of one or more specific causes of impaired defecation (e.g., anterior rectocele, enterocele, inappropriate puborectalis contraction, or pelvic organ prolapse). Dynamic MR defecography (MRD) is considered experimental and investigational (not covered) for the specified indications in the policy because effectiveness has not been established.

Surface thresholds and quick facts

Chronic constipation definitionPresence of 2 or more of: lumpy/hard stools ≥25% of time; sensation of incomplete evacuation ≥25% of time; straining ≥25% of time; two or fewer bowel movements per week for at least 3 months

Specific suspected causes required for coverageAnterior rectocele; Enterocele; Inappropriate contraction of the puborectalis muscle; Pelvic organ prolapse (any one required in addition to chronic constipation and negative/inconclusive anorectal manometry and rectal balloon expulsion)

Investigational categories listedRoutine evaluation of constipation and Dynamic MR defecography (MR defecography) for rectal prolapse, intussusception, other pelvic floor disorders, post‑IPAA evaluation, spinal cord injury neurogenic bowel, obstructed defecation syndrome (examples listed)