High Resolution Anoscopy (HRA)

Policy ID: M-76-007

Section: Diagnostic Medical

Effective Date: September 01, 2019

Revised Date: July 03, 2024

Revision Effective Date: September 02, 2024

Last Reviewed: July 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

High Resolution Anoscopy (HRA) also known as colposcopy of the anal canal is a procedure used in the treatment and surveillance of anal dysplasia and the prevention of anal cancer. It is performed on individuals with an abnormal anal cytology or anal Pap test. Anal Pap tests are obtained on individuals who are at risk for genital or anal human papillomavirus (HPV) infections, even in the absence of signs or symptoms of infection.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

HRA may be considered medically necessary for ANY ONE of the following conditions:

Abnormal anal physical findings (e.g., anogenital warts, hypo-pigmented or hyper-pigmented plaques/lesions, lesions that bleed, high-grade suspicious intraepithelial lesion or any other lesion of uncertain etiology); or
Anal dysplasia found in cytology/biopsy; or
- In individuals with a history of biopsy-proven high-grade dysplasia; or
For biopsy and ablation of high-grade anal intraepithelial neoplasia; or
For anal dysplasia in selected high-risk individuals, e.g., HIV, men who have sex with men (MSM), women with cervical cancer/vulvar high grade dysplasia, and immunosuppressed individuals.

HRA for all other indications is considered experimental/investigational and therefore, non-covered because the safety/and or effectiveness of this service cannot be established by the available peer-reviewed literature.

Procedure Codes

46601

46607

Diagnosis Codes

A63.0

B20

B97.35

B97.7

C21.0

C21.1

C44.520

C78.5

D01.3

D07.1

D12.7

D12.8

D12.9

K62.0

K62.1

K62.5

K62.6

K62.7

K62.9

K62.82

K62.89

N87.0

N87.1

N89.0

N89.3

R85.81

R85.82

R85.610

R85.611

R85.612

R85.613

R85.614

R85.615

R85.616

R85.618

R85.619

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Pre/Post Medical Review 8-10-2020 policy revision and diagnosis codes added

Internal Medical Policy Committee 7-22-2021 Annual Review

Internal Medical Policy Committee 7-21-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 7-26-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 7-16-2024 Coding update - Effective September 02, 2024

Removed diagnosis code N87.2; and
Added diagnosis codes C44.520; D07.1; R85.81 and R85.82; and
Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: M-76-006