Currentsierra health and lifePolicy 2025T0648D

Transanal Minimally Invasive Surgical Procedures (TEMS/TAMIS)

Medical policy governing use of transanal endoscopic microsurgery (TEMS) and transanal minimally invasive surgery (TAMIS) for rectal lesions for UnitedHealthcare Commercial and Individual Exchange plans (except CO for Exchange). Affects providers performing local transanal excisions and payers determining coverage.

Policy Summary

Payersierra health and life

PolicyTransanal Minimally Invasive Surgical Procedures (TEMS/TAMIS)

Policy CodePolicy 2025T0648D

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review Date

Key ActionObtain prior authorization for code 0184T when performing TEMS/TAMIS for excision of rectal tumors consistent with policy indications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

T1N0eligible cancer stage

0184TTEMS code listed

8NCCN distance limit (cm)

2023NCCN guideline year

≈15references

Related Billing Codes

CPT-0184T-TRANSANAL-ENDOSCOPIC-MICROSURGICAL-EXCISION-RECTAL-TUMOR

CPT 0184T: Transanal Endoscopic Microsurgical Excision of Rectal Tumor

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Coverage Criteria for TEMS/TAMIS

Covered Indications

Covered when ALL of the following are met

Indication and staging: Lesion is localized to the rectum verified by endorectal ultrasound or MRI; no evidence of systemic disease

Supported by policy statement

Acceptable lesion types: One of: T1N0 cancer without high-risk features (no deep submucosal invasion, no lymphovascular invasion, not poorly differentiated, not signet‑ring or mucinous carcinoma, no tumor budding); low‑risk malignant pedunculated or sessile polyps; adenomas

Policy lists these specific categories as proven and medically necessary

Anatomic and pathologic criteria (NCCN-aligned): All of the following: lesion involves < 30% circumference of the bowel; size threshold per NCCN (< 3 cm); margin clear (> 3 mm); mobile/nonfixed; within 8 cm of the anal verge; T1 only; no lymphovascular invasion or perineural invasion; well to moderately differentiated; no evidence of lymphadenopathy on pretreatment imaging; full‑thickness excision feasible

Derived from NCCN surgical criteria cited in policy

Transanal Endoscopic Microsurgery (TEMS) and Transanal Minimally Invasive Surgery (TAMIS) are considered unproven and not medically necessary for all indications other than excision of small rectal tumors that meet the policy’s covered criteria. The policy explicitly limits coverage to procedures performed for lesions that are verified as localized to the rectum by endorectal ultrasound or MRI and with no evidence of systemic disease (see covered indications for permitted categories such as T1N0 without high‑risk features, low‑risk malignant polyps, and adenomas).

Specifically, procedures performed for clinical situations outside the listed categories — for example, larger or unfavorably located tumors, lesions with imaging evidence of nodal or systemic disease, or tumors with high‑risk pathologic features — do not meet the policy’s covered indications and are therefore considered not medically necessary. Documentation supporting localization by endorectal ultrasound or MRI and absence of systemic disease is required to establish eligibility under the covered indications.

Applicable Procedure Codes and Coding Details

Applicable Procedure CodesCPT

0184T

Excision of rectal tumor, transanal endoscopic microsurgical approach (i.e., TEMS), including muscularis propria (i.e., full thickness)

NCCN lesion size and location criteria

NCCN lesion size threshold< 3 cm (policy text shows '< 3 mm' but context and brief indicate '< 3 cm')

Circumference limit< 30% of bowel circumference

Proximity to anal vergeWithin 8 cm of the anal verge

Provider Actions, Authorization & Documentation

Prior Authorization

Procedure code requiring authorization

Prior authorization is required for transanal endoscopic microsurgical approach code 0184T when used for excision of rectal tumor consistent with policy criteria. Verify prior authorization requirements with the member's benefit plan before scheduling the procedure.

Prior authorization required for CPT 0184T when billed for excision of rectal tumor via TEMS/TAMIS

Note

Verify member benefits and use of decision support tools

Verify the member-specific benefit plan and any applicable federal or state mandates before applying this policy. Use available decision support tools (for example, InterQual®) and the member's plan document to determine coverage. In the event of a conflict between this policy and the member-specific benefit plan or mandates, the member-specific benefit plan and applicable mandates govern.

Check member-specific benefit plan document and state/federal mandates
Use decision support tools (e.g., InterQual®) as available

Background

TEMS and TAMIS are local transanal surgical approaches that permit excision of rectal lesions using an insufflated rectum to create a working space and magnified visualization for precision resection. These minimally invasive techniques are used as alternatives to radical resection for selected small, localized rectal neoplasms when the lesion and staging meet the policy’s criteria.

Definitions

Adenoma — definition

TermAdenoma

DefinitionA tumor that is not cancer; it starts in gland-like cells of the epithelial tissue (NCI).

Clinical relevanceIncluded as an accepted lesion type for local excision when criteria are met (policy coverage list).

TEMS — Transanal Endoscopic Microsurgery

TermTransanal Endoscopic Microsurgery (TEMS)

DefinitionUse of a fixed rigid resectoscope with insufflation to maintain pneumorectum and provide a stable magnified view through working ports; proprietary instruments operate through two working ports.

Clinical use

Revision History

2025-01-01Template update / new policy versionLatest

Created shared policy version to support application to UnitedHealthcare West plan membership; archived prior policy versions 2024T0648C and MMG202.B.

Policy Summary

Payersierra health and life

PolicyTransanal Minimally Invasive Surgical Procedures (TEMS/TAMIS)

Policy CodePolicy 2025T0648D

Change TypeNo material changes

Effective DateJan 1, 2025

Next Review Date

Key ActionObtain prior authorization for code 0184T when performing TEMS/TAMIS for excision of rectal tumors consistent with policy indications.

SourceLink

On This Page

Note

Endoscopic-first consideration

Before selecting transanal surgery, consider endoscopic resection when endoscopic assessment shows no features suggesting deep submucosal invasion and the lesion is amenable to endoscopic techniques. Endoscopic approaches are generally preferred for benign early rectal neoplasms due to lower morbidity; reserve transanal surgery for lesions with suspected malignancy or when endoscopic resection is not feasible.

Favor endoscopic resection when no endoscopic signs of deep submucosal invasion and lesion is suitable for endoscopic removal
Consider transanal surgery when malignancy is suspected or en bloc/full-thickness excision is required

Documentation Required

Required clinical documentation

Providers must document clinical information demonstrating that the lesion meets policy criteria for TEMS/TAMIS, including localization (endorectal ultrasound or MRI), tumor size and circumferential extent, depth of invasion assessment, absence of lymphadenopathy or systemic disease, histopathologic features (differentiation, lymphovascular invasion, tumor budding), and rationale for selecting transanal surgical approach over endoscopic management.

Documentation of lesion localization by endorectal ultrasound or MRI
Tumor measurements (size, percent circumference) and proximity to anal verge
Endoscopic assessment findings and rationale for surgical approach
Pathology reports showing differentiation and absence/presence of high-risk features
Imaging reports confirming no regional lymphadenopathy or distant disease

Denial Risk

Not medically necessary for other indications

TEMS/TAMIS are not medically necessary for indications other than excision of small rectal tumors that are localized by endorectal ultrasound or MRI and meet the policy's clinical criteria (for example, T1N0 without high-risk features, low-risk malignant polyps, adenomas). Procedures performed for other indications are considered not medically necessary.

Not medically necessary when indications do not meet localization or clinical criteria listed in policy

Note

Member-specific benefit plan governs

Coverage determinations must be based on the member-specific benefit plan and applicable mandates. If the member-specific benefit plan or a federal/state mandate provides coverage that conflicts with this policy, the plan document or mandate prevails. Reference the member-specific benefit plan when making final coverage decisions.

Member-specific benefit plan governs in case of conflict
Check for Medicare NCDs/LCDs or state mandates that may affect coverage

Facilitates excision of small rectal tumors through the anus and may be feasible for more proximal lesions when localized to the rectum.

TAMIS — Transanal Minimally Invasive Surgery

TermTransanal Minimally Invasive Surgery (TAMIS)

DefinitionUse of conventional laparoscopic instruments and cameras with a single-incision port instead of a specialized TEM platform.

Clinical useAlternative minimally invasive approach for local excision of rectal lesions depending on location and extent of disease.

Transanal endoscopic microsurgery (TEM) / TAMIS — overview

DescriptionMinimally invasive transanal local excision techniques (TEMS/TAMIS) that use rectal insufflation and magnified visualization to remove early rectal neoplasms as alternatives to radical resection.

Comparative outcomesEvidence indicates potential benefits in operative time, blood loss, and shorter hospital stay, with variable long-term local recurrence reported in systematic reviews and guideline statements.

IndicationsUsed for small, localized rectal tumors meeting specific anatomic and pathologic criteria (e.g., T1N0 without high-risk features) when full-thickness excision is feasible.