Modifiedhusky_healthPolicy N/A

Transanal Irrigation (TAI) Systems

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Governs prior authorization, medical necessity criteria, contraindications, and documentation requirements for transanal irrigation systems for HUSKY Health (Connecticut Medicaid) providers.

Policy Summary

Payerhusky_health

PolicyTransanal Irrigation (TAI) Systems

Policy CodePolicy N/A

Change TypeContent revised and clarifiedquantity limits updated

Effective DateJan 1, 2025

Last ReviewDec 29, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with a completed form, a prescription signed within required recency (6 months initial; 12 months subsequent), documentation of failed conservative therapy, and pricing information.

SourceLink

POLICY UPDATE CHANGES

Title and content updated to reflect 'Transanal Irrigation (TAI) Systems' and clinical guideline clarified minimum age and prescription timing.

Authorized quantity of TAI catheters (HCPCS A4453) for initial authorization and reauthorization will be allowed up to DSS maximum (31 units/month).

Policy updated throughout to address all anal irrigation systems rather than being specific to Peristeen.

Added statement addressing contraindications and listed reasons for contraindications individually.

>=2 yrsMinimum age for coverage

3 months

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Modifiedhusky_healthPolicy N/A

Transanal Irrigation (TAI) Systems

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Sign up for all husky_health policy alerts

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Governs prior authorization, medical necessity criteria, contraindications, and documentation requirements for transanal irrigation systems for HUSKY Health (Connecticut Medicaid) providers.

Policy Summary

Payerhusky_health

PolicyTransanal Irrigation (TAI) Systems

Policy CodePolicy N/A

Change TypeContent revised and clarifiedquantity limits updated

Effective DateJan 1, 2025

Last ReviewDec 29, 2025

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

Title and content updated to reflect 'Transanal Irrigation (TAI) Systems' and clinical guideline clarified minimum age and prescription timing.

Authorized quantity of TAI catheters (HCPCS A4453) for initial authorization and reauthorization will be allowed up to DSS maximum (31 units/month).

Policy updated throughout to address all anal irrigation systems rather than being specific to Peristeen.

Added statement addressing contraindications and listed reasons for contraindications individually.

>=2 yrsMinimum age for coverage

3 months

Initial authorization period

1 yearSubsequent reauth period

A4453, A4459Listed MEDS supply codes

31/moMax catheters (A4453) per DSS

04/01/2025Revised code desc effective

Coverage Criteria

Initial Authorization Criteria

Covered when ALL of the following are met:

Initial Authorization: The system is used for management of chronic neurogenic bowel dysfunction.

Initial Authorization: Individual is at least 2 years of age.

Initial Authorization: Individual has fecal incontinence, chronic constipation, and/or time-consuming bowel management that significantly impacts quality of life (e.g., inability to participate fully in work or school).

Initial Authorization: Initial management with diet, bowel habit modification, laxatives or constipating medications have failed.

Initial Authorization: No known contraindications exist.

See policy contraindications section for details (e.g., anal/colorectal stenosis, colorectal cancer, recent pelvic radiotherapy, recent relevant surgery, active inflammatory bowel disease, diverticulitis, ischemic colitis, severe autonomic dysreflexia, spinal cord shock phase, recent endoscopic polypectomy/biopsy/EMR/ESD, pregnancy in individuals who have never used TAI).

Reauthorization Criteria

Reauthorization is approved when ALL of the following are met:

Reauthorization: Individual is consistently using the TAI system as directed by their physician.

Reauthorization: The TAI system has been effective in managing fecal incontinence and/or chronic constipation.

Switching device types is treated as a new initial authorization request and requires submission of initial authorization documentation.

Contraindications to transanal irrigation (TAI) are listed to help identify individuals for whom the procedure poses unacceptable risk. TAI is contraindicated in individuals with known anal or colorectal stenosis, colorectal cancer, or who have received radiotherapy to the pelvis. It is also contraindicated after recent major pelvic procedures such as abdominoperineal surgery or any abdominal, anal, or colorectal surgery within the last 3 months, and within 4 weeks of endoscopic polypectomy, colonic biopsy, endoscopic mucosal resection, or endoscopic submucosal dissection. Active inflammatory conditions including active inflammatory bowel disease, diverticulitis, ischemic colitis, and chronic or complex diverticular disease are contraindications, as are severe autonomic dysreflexia and the spinal cord shock phase. Finally, individuals who are pregnant and have never used the system before should not initiate TAI during pregnancy. Note that device manufacturer lists may not be exhaustive; clinicians should consider individual patient factors when assessing appropriateness.

The policy history documents that contraindications were added and clarified over multiple updates to ensure specific conditions are listed individually and clearly. Earlier approvals and updates (2019–2024) added statements addressing contraindications and broadened the policy to apply to all anal irrigation systems; subsequent reviews (2024–2026) refined the procedure and documentation requirements and reiterated that contraindications and reasons for excluding treatment are listed individually in the policy.

Coding and Supply Authorization

MEDS supply codesHCPCSCovered

A4453	Rectal catheter with or without balloon, for use with any type of transanal irrigation system, each.
A4459	Manual transanal irrigation system, includes water reservoir, pump, tubing, and accessories, without catheter, any type

TAI-related HCPCS codes referenced in policy historyHCPCS

A4453	Transanal irrigation catheter (revised description effective 04/01/2025)
A4459	Transanal irrigation system or related code (revised description effective 04/01/2025)
A9999	Previously deleted placeholder HCPCS code referenced in history

inv-07: Initial supply authorization — 3-month supply of catheters up to DSS maximum allowed amount per month

Initial authorization supply periodThree-month authorization period with a 3-month supply of catheters provided when medically necessary.

Quantity limit basisCatheter quantities are limited to the DSS maximum allowed amount per month (see MEDS fee schedule).

Actionable noteInitial authorization includes a three-month supply of catheters up to the DSS maximum per month — confirm monthly quantity against DSS MEDS fee schedule.

inv-08: Subsequent supply authorization — 1-year supply of catheters up to DSS maximum allowed amount per month

Subsequent reauthorization periodSubsequent reauthorizations are granted for one year and include a 1-year supply of catheters when medically necessary.

Provider Actions and Prior Authorization

Prior Authorization

Prior authorization required for TAI systems

Prior authorization is required for all transanal irrigation (TAI) systems; initial and reauthorization requests will be reviewed for medical necessity and must include the clinical and pricing information specified in the policy.

Requests are reviewed in accordance with processes for MEDS/supply coverage determinations.
Coverage determinations are based on submitted case-specific information and medical necessity.

Prior Authorization

Prior authorization applies to A4453 and A4459 (code revisions noted)

Prior authorization is required for HCPCS codes A4453 and A4459. Note that the HCPCS code descriptions for A4453 and A4459 were revised effective 04/01/2025 and quantities are subject to DSS limits.

A4453 and A4459 are the MEDS supply codes referenced for TAI systems.
Revised code descriptions effective 04/01/2025; authorized quantities limited to DSS maximums (see coding thresholds).

Definitions

inv-19: Transanal irrigation (TAI) system — definition and alternative names

Definition (term)Transanal irrigation (TAI) system — a method for bowel management (also called rectal irrigation) used to prevent chronic constipation and fecal incontinence.

Common alternative nameAlso referred to as rectal irrigation.

Typical system componentsSystems may include catheters and a manual irrigation device (reservoir, pump, tubing) used to administer irrigation either independently or with assistance.

inv-20: Medically Necessary / Medical Necessity — statutory definition reference

Statutory referenceMedically Necessary / Medical Necessity is defined per Connecticut General Statutes §17b-259b.

Key elements of definitionServices required to prevent, identify, diagnose, treat, rehabilitate or ameliorate a medical condition and consistent with generally-accepted standards of medical practice.

Background

Transanal irrigation (also called rectal irrigation) is a bowel management technique used to prevent or manage chronic constipation and fecal incontinence. TAI systems typically include a reservoir or pump, tubing, and disposable catheters and may be performed by the individual or with assistance. The therapy is primarily indicated for individuals with chronic neurogenic bowel dysfunction or other causes of refractory bowel dysfunction when conservative measures such as diet, bowel habit modification, and laxatives have failed, and when symptoms significantly affect quality of life.

Revision History

2019-05original_publication

Original publication of the policy (approved May 22, 2019 Medical Reviewer).

2020-04-08clinical_update

Added statement addressing contraindications for treatment and other early updates approved April 8, 2020.

2021-03-22coding_update

Updated HCPCS coding and added HCPCS code A4453; removed placeholder A9999 (approved March 22, 2021 and March 24, 2022 entries reflect coding changes).

Policy Summary

Payerhusky_health

PolicyTransanal Irrigation (TAI) Systems

Policy CodePolicy N/A

Change TypeContent revised and clarifiedquantity limits updated

Effective DateJan 1, 2025

Last ReviewDec 29, 2025

Next Review DateN/A

SourceLink

On This Page

Quantity limit basisCatheter quantities for reauthorization are limited to the DSS maximum allowed amount per month (see MEDS fee schedule).

Actionable noteReauthorization approves a 1-year supply of catheters up to the DSS monthly maximum — verify monthly limits on the DSS MEDS-Medical/Surgical Fee Schedule.

inv-09: Authorized catheter supply limit — Up to 31 units per month for HCPCS A4453 (DSS maximum)

Authorized monthly limit (A4453)Up to 31 units per month for HCPCS A4453 as the DSS maximum allowed amount.

Reference for limitAuthorized quantity clarification was added to the procedure section and tied to the DSS maximum (publication history).

Where to confirm detailsComplete MEDS supply code maximum quantities are available on the DSS CMAP 'MEDS-Medical/Surgical Fee Schedule' at www.ctdssmap.com.

Step Therapy

Conservative therapy must be tried and failed

Coverage requires prior failure of conservative measures: initial management with diet, bowel habit modification, laxatives or constipating medications must have failed before authorization is approved.

Document prior attempts such as oral laxatives, suppositories, enemas, diet and bowel habit changes.

Step Therapy

Switching systems treated as new authorization

Requests for individuals switching from one type of TAI system to another (e.g., Peristeen to Navina) are treated as new initial authorization requests and must include all documentation required for an initial request.

Submit the full initial-authority documentation set when changing device types.

Documentation Required

Initial submission: completed form, prescription, clinical documentation, pricing

Initial requests must include a fully completed Outpatient Prior Authorization Request Form (or online submission), a signed prescription written within the past 6 months by a licensed physician/APRN/PA enrolled in CMAP, supporting clinical documentation, and pricing information (MSRP and AAC).

Fully completed Outpatient Prior Authorization Request Form or online authorization.
Signed prescription within past 6 months from a licensed physician, APRN, or PA enrolled in CMAP.
Clinical documentation within past 6 months supporting medical necessity (failed other bowel management methods, complications).
Manufacturer's suggested retail price (MSRP) and actual acquisition cost (AAC) including discounts.

Documentation Required

Prescription and documentation timing requirements

Prescriptions and clinical documentation for initial authorization must be signed and dated within the past 6 months; for the first reauthorization the same 6-month recency applies, and for all subsequent reauthorizations documentation and prescriptions may be signed within the past 12 months.

Initial request: prescription and documentation signed within 6 months.
First reauthorization: prescription and documentation within 6 months.
Subsequent reauthorizations: prescription and documentation within 12 months.
Prescriptions must be from a licensed physician, APRN, or PA enrolled in CMAP.

Denial Risk

Contraindications that preclude coverage

Coverage is precluded when any listed contraindication is present; providers must not submit requests for individuals with these contraindications.

Known anal or colorectal stenosis
Colorectal cancer
Radiotherapy to the pelvis
Recent abdominoperineal surgery
Active inflammatory bowel disease
Diverticulitis
Ischemic colitis
Chronic and complex diverticular disease
Abdominal, anal or colorectal surgery within the last 3 months
Within 4 weeks of endoscopic polypectomy, recent colonic biopsy, recent endoscopic mucosal resection or sub-mucosal dissection
Severe autonomic dysreflexia
Spinal cord shock phase
Pregnant individuals who have not used the system before

Denial Risk

Payment contingent on active eligibility and medical necessity

Authorization decisions are based on medical necessity at the time the authorization is issued and do not guarantee payment; payment is contingent on the member having active coverage, benefits and applicable policies at time of service.

Verify member eligibility and benefits at the time of service to reduce risk of claim denial.

Additional criteriaMust be clinically appropriate in type, frequency, timing, site, extent and duration; not primarily for convenience; and cost-effective compared to alternatives.

inv-21: Transanal Irrigation (TAI) System — device and disposable catheter definition

Device definitionTransanal irrigation (TAI) system — device and associated disposable catheters used to perform anal/colonic irrigation to manage bowel dysfunction and fecal incontinence.

Disposable componentRectal catheter with or without balloon (HCPCS A4453) is considered a disposable catheter component of the TAI system.

System components exampleManual TAI systems include a water reservoir, pump, tubing, and accessories (HCPCS A4459 describes manual system components without catheter).

2023-03-27scope_update

Policy updated throughout to address all anal irrigation systems rather than being specific to Peristeen and clarified authorization for switching systems (approved March 27, 2023).

2024-12-27procedural_update

Procedure updated to require prescriptions signed and dated within 12 months for initial and reauthorizations; clarified manual pump anal irrigation reference (approved December 27, 2024).

2025-04-01code_description_revision

HCPCS code descriptions for A4453 and A4459 revised effective April 1, 2025.

2026-04-02quantity_and_timing_clarificationLatest

Procedure clarified that authorized quantity for HCPCS A4453 is allowed up to the DSS maximum (31 units/month) and prescription/clinical documentation timing was revised (approved April 2, 2026; CHNCT approvals through April 2026).