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    v1.0.28
    OpenPayerPolicy UpdatesGastroenterologyselect_health Peristeen coverage update | OpenPaye…
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    Currentselect_healthPolicy CCP.1246

    Peristeen® anal irrigation system

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    Coverage criteria and medical necessity guidance for use of the Peristeen transanal irrigation system for bowel management, affecting Select Health of South Carolina members and treating providers.

    Policy Summary
    Payerselect_health
    PolicyPeristeen® anal irrigation system
    Policy CodePolicy CCP.1246
    Change TypeAdded indication for low anterior resection syndromeother clarifications and reference updates
    Effective DateAug 1, 2025
    Last ReviewAug 1, 2025
    Next Review DateDec 1, 202639d
    Key ActionObtain prior authorization and document that member meets all coverage criteria; continued use requires medical review every six months.
    SourceLink
    POLICY UPDATE CHANGES

    An indication for members with low anterior resection syndrome was added based on new literature.

    Findings section was rewritten, removing references prior to 2014 and adding a new systematic review and meta-analysis (Bolia, 2024).

    Updated references in 2025 with no policy changes warranted.

    ≥2 yrsminimum age
    6 monthsreview interval
    40–73%success rates

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    35–55%
    discontinuation
    62%pooled pediatric success

    Coverage and Medical Necessity Criteria

    Neurogenic bowel dysfunction 6mdash; Initial approval

    Covered when ALL of the following are met

    Primary criteria set: The system is used for the management of neurogenic bowel dysfunction.

    Per FDA indication and guideline evidence

    Primary criteria set: Member experiences fecal incontinence, chronic constipation, or time-consuming bowel management procedures.

    Symptom indications described in policy

    Primary criteria set: Initial management (diet, bowel habit modification, laxatives, or constipating medications) has failed.

    Transanal irrigation considered after failed conservative management

    Low anterior resection syndrome and select pediatric non-neurogenic cases

    Also covered when ANY of the following apply in addition to failed conservative management

    Additional indications: Low anterior resection syndrome (transanal irrigation may improve bowel function and reduce symptom severity; particularly helpful for incomplete evacuation).

    Supported by randomized trials and systematic reviews (Emile 2023; Ansar 2024)

    All uses of the Peristeen anal irrigation system that are not explicitly listed in the coverage criteria are considered investigational and not medically necessary. This includes any indication beyond the covered scenarios for management of neurogenic bowel dysfunction, low anterior resection syndrome (LARS), and the specified qualifying pediatric non-neurogenic bowel dysfunction cases described in the criteria. Continued approval for covered uses requires medical review every 6 months to confirm compliance and ongoing need.

    Use of the Peristeen anal irrigation system for indications beyond those specifically enumerated in this policy is not covered. Such uses are considered investigational/not clinically proven and therefore are not medically necessary. Providers should not expect coverage for Peristeen when the member’s condition does not meet the policy’s stated qualifying diagnoses and clinical requirements.

    Provider Requirements, Documentation, and Authorization

    Prior Authorization

    Prior authorization and continued approval required

    Peristeen may be approved only when the policy's coverage criteria are met; continued use requires medical review every six months to confirm compliance and ongoing need for treatment.

    • Prior authorization required to confirm member meets all coverage criteria (neurogenic bowel or qualifying LARS or pediatric non‑neurogenic indication, age ≥ 2 years, fecal incontinence/chronic constipation/time‑consuming bowel management, and failed initial conservative management).
    • Continued approval: medical review every 6 months to establish continued compliance and need.
    Step Therapy

    Use after failed conservative management, before invasive surgery

    Transanal irrigation (Peristeen) is positioned after initial conservative management has failed and is considered before proceeding to more invasive surgical procedures.

    • Initial conservative management includes diet, bowel habit modification, laxatives, or constipating medications.

    Background and Definitions

    Fecal incontinence and chronic constipation have both organic and functional causes; for chronic organic causes such as neurogenic bowel dysfunction, bowel management focuses on producing predictable evacuation by adjusting stool consistency and, when needed, using mechanical evacuation methods like transanal irrigation. The Peristeen system is a pump‑based transanal irrigation method used to mechanically evacuate the colon to prevent or reduce chronic constipation and fecal incontinence. Continued approval of Peristeen requires medical review every 6 months to confirm compliance and ongoing need.

    Transanal irrigation / Peristeen — device description
    Device componentsControl unit with a manual pump, detachable water bag, and rectal catheter with an inflatable (soft) balloon to create a watertight seal
    FunctionManual transanal irrigation system used to mechanically evacuate the colon by regular irrigation and an inflatable rectal balloon to maximize fecal removal
    Balloon purposeInflatable rectal balloon secures catheter inside the bowel and creates a watertight system during irrigation
    User operationCan be administered independently by the patient or with assistance
    Policy Summary
    Payerselect_health
    PolicyPeristeen® anal irrigation system
    Policy CodePolicy CCP.1246
    Change TypeAdded indication for low anterior resection syndromeother clarifications and reference updates
    Effective DateAug 1, 2025
    Last ReviewAug 1, 2025
    Next Review DateDec 1, 202639d
    Key ActionObtain prior authorization and document that member meets all coverage criteria; continued use requires medical review every six months.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaProvider Requirements, Documentation, and AuthorizationBackground and Definitions
  1. Alternative covered services listed include multifaceted bowel management programs, medications, behavioral therapies, neuromodulation, and surgical options.
    2. Documentation Required

    Required clinical documentation and 6‑month ongoing review

    Document that the member meets all coverage criteria and retain records for ongoing reviews; continued approval requires medical review every six months.

    • Documentation must show diagnosis (neurogenic bowel dysfunction, qualifying LARS, or pediatric non‑neurogenic bowel dysfunction up to age 21), age ≥ 2 years (or pediatric criteria), presence of fecal incontinence, chronic constipation, or time‑consuming bowel management, and failure of initial conservative management.
    • Document ongoing benefit and compliance for each 6‑month medical review to support continued coverage.
    Denial Risk

    Not medically necessary for other uses — may be denied

    Claims for Peristeen for indications other than those specified in the policy are investigational and are not medically necessary and may be denied.

    • Not covered indications include uses beyond neurogenic bowel dysfunction, low anterior resection syndrome, or qualifying pediatric non‑neurogenic bowel dysfunction up to age 21.
    • All other uses are listed as investigational/not clinically proven and therefore not medically necessary.
    Regulatory/indication noteRegulated by the U.S. FDA as a Class II device; indicated for ages ≥2 years with neurogenic bowel dysfunction for fecal incontinence, chronic constipation, or time-consuming bowel management