Plugs for Enteric and Anorectal Fistula Repair
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This policy governs coverage of biosynthetic fistula plugs, including porcine small intestine submucosa and synthetic-material plugs, used to repair enteric and anal fistulas. Contract terms take precedence where applicable.
No material clinical or coverage changes in this revision.
Coverage Criteria
Enteric and anal fistula plugs
The following service is considered investigational.
No clinical exception or covered indication is stated in this policy section.
Enteric and anal fistula plug repair
Biosynthetic fistula plugs are considered investigational for repair of enteric and anal fistulas.
Available research does not demonstrate improved healing or reduced recurrence, and no practice guidelines recommend these plugs for any indication.
Repair of enteric or anal fistulas using biosynthetic fistula plugs—including plugs made from porcine small intestine submucosa or synthetic material—is considered investigational under this policy.
Coding
| K050337 | SIS Fistula Plug and Surgisis RVP Recto-Vaginal Fistula Plug; FDA 510(k) approval number; Cook Biotech Inc.; approved 3/9/2005 and 10/10/2006, respectively |
| K062729 | Surgisis RVP Recto-Vaginal Fistula Plug; FDA 510(k) approval number; Cook Biotech Inc.; approved 10/10/2006 |
| K082682 | Surgisis Biodesign Enterocutaneous Fistula Plug; FDA 510(k) approval number; Cook Biotech Inc.; approved 2/27/2009 |
| K083266 | GORE BIO-A Fistula Plug; FDA 510(k) approval number; W.L. Gore & Associates, Inc.; approved 3/27/2009 |
| K150668 | Biodesign Enterocutaneous Fistula Plug; FDA 510(k) approval number; Cook Biotech Inc.; approved 12/09/2015 |
Provider Actions
Investigational fistula plug procedure
Coverage may be denied because biosynthetic fistula plugs—including plugs made from porcine small intestine submucosa or synthetic material—are considered investigational for repair of enteric and anal fistulas. Applicable contract language takes precedence, and contracts may exclude investigational services.
Investigational fistula plug repair
Claims for biosynthetic fistula plugs used to repair enteric or anal fistulas may be denied because the policy considers these services investigational. This includes plugs made from porcine small intestine submucosa or synthetic material.
Clinical Background
Fistula plugs are placed within an abnormal enteric or anorectal passage and anchored to provide a scaffold for new tissue growth, promote healing and closure, and allow drainage while healing progresses. The plug is designed to be absorbed in approximately 6–8 weeks. Enteric fistulas may connect the gastrointestinal tract with abdominal organs, the chest, or the skin; anal fistulas connect the anal canal or rectum with the skin or other pelvic structures.
Clinical management of fistulas may include drainage and infection control, nutritional therapy, fistulotomy or fistulectomy, advancement flaps, setons, LIFT procedures, or fibrin glue. The policy's evidence review describes limited and generally low-quality evidence for fistula plugs, including findings of higher healing with advancement flap in some analyses and more six-week complications in the plug group in the FIAT randomized trial.
Definitions
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