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CurrentCurativePolicy CHP-IP-2026-147

Abdominoperineal Resection (APR)

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This policy governs medical necessity, inpatient level of care, continued stay, discharge readiness, and documentation for open, laparoscopic, or robotic abdominoperineal resection with permanent end colostomy and perineal closure or flap reconstruction in adults 18 years and older.

Policy Summary

PayerCurative

PolicyAbdominoperineal Resection (APR)

Policy CodePolicy CHP-IP-2026-147

Change TypeAdministrative version update

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the operative plan, perioperative risk information, and operative note to support authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Adults 18+Applicable population

4-7 daysExpected uncomplicated stay

6-9 daysStay with flap reconstruction

NEWS2 ≥7ICU assessment threshold

28 daysCancer VTE prophylaxis

Medical Necessity and Level-of-Care Criteria

Initial inpatient admission

Acute inpatient admission for abdominoperineal resection is medically necessary when ALL of the following are met.

APR inpatient medical necessity

Procedure indication
- Low rectal adenocarcinoma: Tumor involves the anal sphincter complex or levators, or sphincter-preserving resection cannot achieve clear margins or acceptable function, supported by pelvic MRI and applicable rectal cancer guidance.
- Persistent or recurrent anal squamous cell carcinoma: Biopsy-proven persistent disease, generally assessed up to approximately 26 weeks after chemoradiation, or local recurrence.Up to approximately 26 weeks after chemoradiation for response assessment

Policy Summary

PayerCurative

PolicyAbdominoperineal Resection (APR)

Policy CodePolicy CHP-IP-2026-147

Change TypeAdministrative version update

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the operative plan, perioperative risk information, and operative note to support authorization.

SourceLink

On This Page

Severe benign disease is not amenable to sphincter preservation, such as refractory Crohn perianal disease or radiation injury with fecal incontinence and fistula.

Inpatient setting required

APR postoperative requirement: APR requires inpatient postoperative care because of pelvic dissection, the perineal wound, and creation of a new colostomy.
Elevated perioperative risk: ASA physical status III or higher, or documented frailty, with anticipated postoperative physiologic monitoring beyond observation capability.ASA III or higher
Significant comorbidity: Comorbidity requires inpatient perioperative management, including heart failure with LVEF 40% or less or NYHA class III-IV symptoms; insulin-treated diabetes requiring intravenous insulin or frequent titration; obstructive sleep apnea requiring parenteral opioids and continuous oximetry; CKD stage 4-5 or dialysis; or therapeutic anticoagulation requiring bridging.LVEF ≤40% or NYHA III-IV; CKD stage 4-5 or dialysis
Intraoperative change in expected course: Blood loss requiring transfusion, conversion to an open approach, unplanned additional organ resection, or a difficult airway changes the expected course.

Observation or outpatient evaluation

Observation or outpatient care is appropriate only for the related evaluation procedures below.

Related evaluation procedure: Examination under anesthesia and biopsy to confirm persistent or recurrent disease are ordinarily performed on an outpatient basis.

No observation pathway applies to APR itself.

Intensive care unit

ICU care is appropriate when ANY of the following is documented.

ICU criteria

Major surgical complication: Anastomotic leak with sepsis, planned relook laparotomy, or open abdomen.
Shock or vasoactive support: Vasopressor or inotrope infusion is required to maintain mean arterial pressure of at least 65 mmHg, or septic shock is present.MAP ≥65 mmHg; septic shock: lactate >2 mmol/L despite adequate fluid resuscitation
Severe respiratory failure: Invasive mechanical ventilation or escalating noninvasive support is required for acute respiratory failure.SpO2 <90% despite FiO2 ≥0.6, or pH <7.25 with rising PaCO2
Unstable hemorrhage: Active hemorrhage causes hemodynamic instability or activates a massive transfusion protocol, with return to the operating room or angioembolization pending.
Persistent high NEWS2: NEWS2 of 7 or higher persists after initial treatment and the physician documents a need for organ support or continuous one-to-one monitoring.NEWS2 ≥7

Step-down or intermediate care

Step-down or intermediate care is appropriate when ANY of the following is documented and no ICU criterion is present.

Step-down criteria

Flap or epidural monitoring: A myocutaneous flap requires hourly checks, or epidural analgesia causes hypotension after pelvic dissection.Hourly flap checks
Intermediate NEWS2: NEWS2 of 5-6 or a single parameter score of 3 requires vital signs at least every 1-2 hours without organ-support need.NEWS2 5-6 or single parameter score 3
Significant arrhythmia: A new or hemodynamically significant arrhythmia requires continuous cardiac monitoring and rate-control titration.
Stable respiratory or opioid monitoring need: Noninvasive ventilation or high-flow nasal oxygen is required in an otherwise stable patient, or obstructive sleep apnea with parenteral opioids requires continuous pulse oximetry and capnography.

Medical-surgical unit

Medical-surgical unit care is appropriate when ANY of the following applies.

Medical-surgical criteria

Routine postoperative care: Colostomy teaching, perineal wound care, positioning restrictions after flap, and mobilization are required.
Stable hospital-level treatment: The patient is hemodynamically stable with NEWS2 of 0-4 and requires parenteral or epidural analgesia, intravenous fluids or antibiotics, drain or wound management, or monitored diet advancement.NEWS2 0-4
Routine vital-sign monitoring: Vital signs every 4 hours are adequate and no ICU or step-down criterion is present.Every 4 hours

Discharge readiness

The patient is ready for discharge from acute care when ALL of the following are met.

Temperature is below 38.0 C for at least 24 hours, or a fever source is identified with an oral or outpatient treatment plan.<38.0 C for ≥24 hours
Stable vital signs: Vital signs are stable on room air or the baseline home oxygen requirement.NEWS2 0-4 for 12-24 hours
Pain control: Pain is controlled on oral analgesics with an opioid-sparing discharge regimen documented.
Nutrition: Oral fluids and diet are tolerated, or an enteral or parenteral nutrition plan is arranged.
Laboratory stability: Hemoglobin is stable without transfusion, and creatinine and electrolytes are at or near baseline or have a follow-up plan.No transfusion for ≥24 hours
Mobility and transition: Mobility is at the expected post-procedure level or safe transfer to documented post-acute care is arranged; medication reconciliation, VTE prophylaxis, wound and drain instructions, return precautions, and follow-up are documented.
Bowel and stoma function: Flatus or stool has returned; a regular or soft diet is tolerated without vomiting; the colostomy is functioning with self-care demonstrated or home health arranged; and the perineal wound is intact or has a wound-care plan.
Cancer VTE prophylaxis: Extended venous thromboembolism prophylaxis is arranged after cancer resection.28 days

Continued acute inpatient stay

Continued acute inpatient stay is medically necessary when ANY of the following is documented at each review.

Continued-stay criteria

High-acuity care: Any ICU or step-down level-of-care criterion is present, or NEWS2 is 5 or higher.NEWS2 ≥5
Non-lower-level IV treatment: Intravenous therapy cannot be provided at a lower level of care, such as IV antibiotics without an oral or outpatient infusion option, initiation of parenteral nutrition, or IV analgesia.
Intake or ileus problem: The patient cannot tolerate oral intake, or ileus requires nasogastric decompression.
Pending acute intervention: An urgent procedure, imaging study, or consultation expected within 24 hours is pending and could change acute management.Within 24 hours
Pelvic or anastomotic complication: Anastomotic leak, pelvic abscess, or fistula requires image-guided drainage, IV antibiotics, or reoperation.
Obstruction or ileus: Ileus or small-bowel obstruction requires nasogastric decompression or parenteral nutrition.
Stoma-related metabolic complication: High-output ileostomy with acute kidney injury or electrolyte derangement requires IV replacement.
Wound complication: A perineal or abdominal wound complication requires inpatient debridement or IV antibiotics.
Flap compromise or dehiscence: Perineal flap compromise or wound dehiscence requires initiation of negative-pressure therapy or operative revision.

Extended-stay review

Days beyond the expected benchmark are supported when ANY extended-stay trigger is documented with clinical evidence and an active treatment plan.

Extended-stay triggers

Perineal wound infection or dehiscence: Active perineal wound infection or dehiscence is documented.
Flap compromise: Myocutaneous flap compromise is documented.
Ileus is documented and requires ongoing acute management.
Urinary or ureteral complication: Urinary retention or ureteral injury is documented.
Pelvic abscess is documented with an active treatment plan.

Preoperative admission more than one day before surgery for scheduling, travel, or convenience is excluded from medical necessity unless a documented medical reason supports the additional inpatient time. Preoperative evaluation and preparation can generally be completed on an outpatient basis.

Custodial, respite, or convenience days do not meet medical necessity for acute inpatient care. These days should be referred for physician review rather than supported as acute-level hospitalization.

Abdominoperineal resection for anal squamous cell carcinoma is not medically necessary before completion of chemoradiation and the response-assessment period when there is no documented progression. Chemoradiation is the primary treatment, and tumor regression may continue for approximately 26 weeks; such requests require physician review.

Continued inpatient stay after all discharge-readiness criteria are met is not acute-level care. This includes days spent awaiting post-acute placement, transportation, or equipment when no acute medical need remains. The case should be referred to discharge planning and physician review; days already authorized are not reversed retroactively.

Coding and Utilization Reference

ICD-10-CM rectal and anal malignancyICD-10

C20	Malignant neoplasm of rectum
C21.0	Malignant neoplasm of anus, unspecified
C21.1	Malignant neoplasm of anal canal
C21.2	Malignant neoplasm of cloacogenic zone
C21.8	Malignant neoplasm of overlapping sites of rectum, anus and anal canal

ICD-10-PCS rectal and anal resectionICD-10

0DTP0ZZ	Resection of rectum, open approach
0DTQ0ZZ	Resection of anus, open approach
0DTP4ZZ	Resection of rectum, percutaneous endoscopic approach
0DTQ4ZZ	Resection of anus, percutaneous endoscopic approach

CPT abdominoperineal proctectomyCPT

45110	Abdominoperineal proctectomy, open
45395	Abdominoperineal proctectomy, laparoscopic

MS-DRG FY2027 v44Revenue

332	Rectal resection with MCC
333	Rectal resection with CC
334	Rectal resection without CC/MCC

Facility revenue codesRevenue

0120	Facility revenue code
0121	Facility revenue code
0200	Facility revenue code
0206	Facility revenue code
0270	Facility revenue code
0360	Facility revenue code
0370	Facility revenue code
0710	Facility revenue code
0762	Facility revenue code

NEWS2 ICU threshold

NEWS2 threshold7 or higher

PersistencePersists after initial treatment

Required supportDocumented need for organ support or continuous one-to-one monitoring

Septic shock

Vasopressor criterionVasopressor requirement

Lactate criterionLactate above 2 mmol/L

Resuscitation statusDespite adequate fluid resuscitation

Acute respiratory failure

Oxygenation criterionSpO2 below 90% despite FiO2 of 0.6 or higher

Acid-base criterionpH below 7.25 with rising PaCO2

Respiratory supportInvasive mechanical ventilation or escalating noninvasive support

NEWS2 step-down threshold

NEWS2 range5-6

Single-parameter thresholdA single parameter score of 3

Monitoring requirementVital signs at least every 1-2 hours without need for organ support

Stable medical-surgical acuity

NEWS2 range0-4

Higher-acuity criteriaNo criterion for ICU or step-down care is present

Monitoring levelVital signs every 4 hours are adequate

Expected stay

Uncomplicated course4-7 days

Myocutaneous flap reconstruction6-9 days

Use of benchmarkPlanning benchmark for concurrent review, not a limit on covered days

CMS FY2027 geometric mean LOS

MS-DRG 332Rectal resection with MCC: 5.8 days

MS-DRG 333Rectal resection with CC: 3.3 days

MS-DRG 334Rectal resection without CC/MCC: 2.2 days

Authorization and Documentation Requirements

Prior Authorization

APR Medical-Necessity Authorization

Request acute inpatient admission for abdominoperineal resection (APR) when an eligible indication is documented and the inpatient setting is medically necessary. APR requires inpatient postoperative care because of pelvic dissection, perineal wound management, and creation of a new colostomy; inpatient need may also be supported by ASA III or higher, frailty, significant comorbidity requiring inpatient management, or an intraoperative event that changes the expected course.

Eligible indications include low rectal adenocarcinoma involving the anal sphincter complex or levators, or inability to achieve clear margins or acceptable function with sphincter-preserving resection.
Eligible indications also include biopsy-proven persistent anal squamous cell carcinoma generally assessed up to 26 weeks after chemoradiation, local recurrence, or severe benign disease not amenable to sphincter preservation.
Document relevant inpatient factors, including heart failure with LVEF ≤40% or NYHA III-IV symptoms, insulin-treated diabetes requiring intravenous insulin or frequent titration, obstructive sleep apnea requiring parenteral opioids and continuous oximetry, CKD stage 4-5 or dialysis, therapeutic-anticoagulation bridging, transfusion, conversion to open surgery, unplanned additional organ resection, or difficult airway.

Prior Authorization

Level-of-Care Authorization

Assign and authorize the level of care that matches the documented acuity. ICU, step-down/intermediate, and medical-surgical placement require objective clinical findings and physician documentation; step-down criteria apply only when no ICU criterion is present.

ICU: anastomotic leak with sepsis, planned relook laparotomy or open abdomen; vasopressor/inotrope support to maintain MAP ≥65 mmHg or septic shock; invasive ventilation or escalating noninvasive support for acute respiratory failure; active hemorrhage with instability or massive-transfusion activation; or persistent NEWS2 ≥7 requiring organ support or continuous one-to-one monitoring.
Step-down/intermediate: myocutaneous flap requiring hourly checks; epidural-related hypotension; NEWS2 5-6 or a single parameter score of 3 requiring vital signs every 1-2 hours; new hemodynamically significant arrhythmia requiring continuous monitoring and titration; stable noninvasive ventilation/high-flow oxygen; or obstructive sleep apnea requiring parenteral opioids with continuous pulse oximetry and capnography.
Medical-surgical: postoperative colostomy teaching, perineal wound care, flap-related positioning restrictions, and mobilization; stable NEWS2 0-4 with ongoing hospital-level analgesia, fluids, antibiotics, drain/wound care, or diet advancement; or need for four-hour vital signs without ICU or step-down criteria.

Documentation Required

Continued-Stay Authorization

Submit documentation supporting each continued acute inpatient day. Continued stay is medically necessary when at least one acute need remains documented at each review, with active treatment and the reason a lower level of care is insufficient.

Any ICU or step-down criterion, or NEWS2 ≥5.
Intravenous therapy unavailable at a lower level of care; inability to tolerate oral intake; ileus requiring nasogastric decompression; or parenteral nutrition initiation.
Urgent procedure, imaging, or consultation expected within 24 hours that may change acute management.
Anastomotic leak, pelvic abscess, fistula, ileus, small-bowel obstruction, high-output ileostomy with acute kidney injury/electrolyte derangement, or wound/flap complication requiring inpatient treatment, drainage, intravenous therapy, negative-pressure therapy initiation, or operative revision.
Review at least daily in ICU or step-down care and at least every 48 hours on the medical-surgical unit; also review when a red flag occurs or the expected-length-of-stay benchmark is reached. The uncomplicated benchmark is 4-7 days, or 6-9 days with myocutaneous flap reconstruction, and is not a limit on covered days.

Documentation Required

Procedure and Perioperative Record

Include the procedure and perioperative record needed to establish the indication, operative risk, approach, and changes in the expected course.

Operative or procedure plan specifying the indication, staging or classification, and approach: open, laparoscopic, or robotic.
ASA physical status, relevant comorbidities, and anesthesia risk assessment.
Operative note with estimated blood loss, transfusion, intraoperative events, and drains or devices placed.

Documentation Required

Concurrent Review and Acuity Documentation

Support concurrent review with daily clinical and treatment documentation that establishes current acuity, response, and the specific reason acute inpatient care remains necessary.

Daily progress notes with vital signs or NEWS2, intake and output, drain output, laboratory trends, active treatment, response to treatment, and the specific reason acute care is still needed.
Document the assigned level of care and the objective finding supporting ICU or step-down placement when used.
Record clinically relevant changes, escalation or de-escalation of monitoring and treatment, and any red flag prompting reassessment.

Documentation Required

Discharge and Surgical Transition Plan

Document discharge readiness and the surgical transition plan before discharge, including the services, education, and post-acute arrangements needed for a safe transition.

Discharge readiness assessment and transition plan, including post-acute referral when applicable.
Stoma marking and plan for perineal closure.
Colostomy teaching, wound and flap-care instructions, mobility or positioning restrictions, follow-up, and equipment or transportation planning when applicable.

Documentation Required

Disease-Specific Supporting Records

Provide disease-specific records supporting the APR indication, treatment timing, and anatomic or pathologic findings.

Pelvic MRI documenting the relationship of the tumor to the sphincters and levators.
Biopsy confirming persistent or recurrent anal carcinoma, including timing after chemoradiation when applicable.
Relevant oncologic staging, chemoradiation history, response assessment, recurrence documentation, and related clinical records.

Documentation Required

Support the Requested Amount

Ensure the requested quantity, units, and duration are supported by the clinical documentation and active treatment plan.

Document the number of inpatient days, level-of-care days, services, units, or other requested increments.
If only part of the request is supported, the supported portion may be approved and only the unsupported increment is referred for review.

Denial Risk

Premature Salvage APR

APR for anal squamous cell carcinoma before completion of chemoradiation and the response-assessment period, without progression, does not meet medical-necessity criteria for automatic approval.

Chemoradiation is the primary treatment, and regression can continue for up to approximately 26 weeks.
Refer the request for physician review; do not issue an automated or non-physician adverse determination.

Denial Risk

Unnecessary Preoperative Days

Preoperative admission more than one day before surgery is not medically necessary when used for scheduling, travel, or convenience without a documented medical reason.

Preoperative evaluation and preparation can generally be completed as an outpatient.
Refer for physician review when a medical reason for the additional preoperative days is not documented.

Denial Risk

Stay After Discharge Readiness

Continued inpatient days after all discharge-readiness criteria are met do not meet acute inpatient medical-necessity criteria when the patient is only awaiting placement, transportation, or equipment without an acute need.

Direct the case to discharge planning and physician review.
Days already authorized are not reversed retroactively.

Denial Risk

Custodial or Convenience Days

Custodial, respite, or convenience days are not medically necessary at the acute inpatient level.

Refer for physician review rather than issuing an adverse determination through an automated system or non-physician review.
Document any acute medical need if continued inpatient care is requested.

Denial Risk

Postoperative Red Flags

Immediately escalate postoperative findings that may indicate wound or flap failure, stoma ischemia, sepsis, hemodynamic or respiratory deterioration, thromboembolism, or another unsafe condition.

Perineal wound purulence, flap discoloration, or wound separation: obtain surgical evaluation, consider imaging for pelvic abscess, and initiate antibiotics or debridement as indicated.
Dusky or retracted colostomy: obtain urgent bedside assessment of stoma viability and surgical revision if ischemic.
NEWS2 ≥7, new systolic blood pressure <90 mmHg, or new oxygen requirement >6 L/min: activate rapid response or emergency evaluation and reassess for ICU transfer.
Suspected sepsis, including new organ dysfunction with suspected infection or lactate >2 mmol/L: obtain urgent physician evaluation, cultures, antibiotics, and source-control imaging; transfer to ICU if vasopressors are needed.
Signs of pulmonary embolism or deep-vein thrombosis, including unexplained tachycardia, hypoxemia, pleuritic pain, or unilateral leg findings: obtain urgent imaging and make an anticoagulation decision; discharge is unsafe until evaluated.

Documentation Required

Criteria Not Met

Requests that do not satisfy the stated criteria must be referred for physician review. Automated systems and non-physician clinical reviewers may approve in full or in part but may not issue an adverse determination.

Only a licensed physician of the same or similar specialty may issue an adverse determination after offering the requesting provider a peer-to-peer discussion and meeting applicable licensure, specialty, and medical-director requirements.
The absence of a criterion addressing a service is not itself a basis for an adverse determination; the physician applies generally accepted standards of medical practice.
Concurrent review applies to each continued-stay period. Days already authorized are not retroactively denied, and expected length of stay is a planning benchmark, not a limit on covered days.

Documentation Required

Requested Amount Exceeds Documentation

When the requested quantity, units, or duration exceed what the documentation supports, separate the supported portion from the unsupported increment.

Approve the supported portion when criteria are met.
Refer only the excess quantity, units, or duration for physician review; do not treat the entire request as unsupported solely because an increment exceeds the documentation.

Procedure Background

APR may be performed through an open, laparoscopic, or robotic approach. The perineal wound may be closed primarily or reconstructed with a myocutaneous flap, particularly when pelvic radiation or other factors increase the risk of wound complications. Perineal wound complications are a major cause of prolonged hospitalization and readmission.

Policy Definitions

Clinical severity findings

Examination findingsObjective, documented examination findings may establish acuity

Physiologic findingsVital-sign and laboratory findings may establish acuity

Other supporting findingsImaging or validated-score findings may establish acuity

Hospital-level services required

Setting limitationServices cannot be delivered safely in observation, ambulatory, home, or post-acute settings

Intravenous therapyFrequent titration of intravenous therapy may require hospital-level services

Monitoring or proceduresContinuous monitoring or procedures with significant early complication risk may require hospital-level services

Expected length of stay

PurposePlanning benchmark for an uncomplicated course

ReferenceCMS FY2027 MS-DRG geometric mean length of stay

Coverage interpretationNot a limit on covered days

NEWS2

Score componentsRespiratory rate, oxygen saturation, supplemental oxygen, systolic blood pressure, heart rate, level of consciousness, and temperature

Urgent reviewA score of 5-6 or a single parameter score of 3 prompts urgent review

Emergency responseA score of 7 or more prompts emergency response

ASA physical status

ClassificationAmerican Society of Anesthesiologists classification of preoperative comorbidity

ASA class IIISevere systemic disease

ASA class IVSevere systemic disease that is a constant threat to life