Clinical Policy: Robotic Surgery Reference Number: CP.MP. 207

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1 Clinical Policy: Robotic Surgery Reference Number: CP.MP. 207 Effective Date: 03/05 Last Review Date: 10/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Surgical use of robotics, or computer-assisted surgical systems (CAS), has evolved over the last 30 years. Using ongoing technological advances in computer software and robotic engineering, robotic surgery is aimed at improving surgical outcomes through increased precision in a setting of minimal invasiveness through intuitive instrument control and depth perception. Policy/Criteria I. It is the policy of Health Net of California that robotic-assisted surgery is proven as equivalent to, but not superior to, a standard minimally invasive surgical approach, where the standard minimally invasive surgical approach is itself supported by clinical evidence. It is a method of performing the procedure and not a separate service. This policy includes any type of robotically assisted surgery such as prostate, cardiac, gastrointestinal, urology and gynecological etc. II. It is the policy of Health Net of California that additional reimbursement will not be provided for the use of robotic surgical devices (e.g., da Vinci Surgical System, ZEUS Robotic Surgical System). The type of instruments, technique or approach used in a procedure is a matter of choice of the surgeon. Additional professional or technical reimbursement will not be made when a surgical procedure is performed using robotic assistance. Reimbursement for procedures in which a robotic surgical system is used will be based on the contracted rate or usual and customary fee for the base procedure. Separate reimbursement is not allowed for the robotic surgical technique. Reimbursement for the base procedure may be subject to medical necessity review. Background Robotic-assisted surgery Robotic-assisted surgery, with CAS, is typically used in laparoscopic rather than open surgical approaches. The goal of robot-assisted laparoscopy is proposed to assist surgeons in improving patient care by converting procedures that would have otherwise been performed by laparotomy into minimally invasive procedures. Conventional and Robotic Laparoscopy Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions. However, both of these minimally invasive routes have introduced trocar injuries, insufflation related problems, and trocar-site abdominal wall hematomas when compared with laparotomy. As with conventional laparoscopy, there is an increased risk of bladder and ureteral injury with robotassisted laparoscopy compared to open surgery. 7 Page 1 of 5

2 Da Vinci Surgical System The Da Vinci Surgical System is a robotic surgical system that was approved by the Food and Drug Administration (FDA) in 2000, to facilitate complex surgery using a minimally invasive approach, and is controlled by a surgeon from a console. Advancing Minimally Invasive Gynecology Worldwide (AAGL) AAGL recommends: The available evidence demonstrates the feasibility and safety of roboticassisted laparoscopic surgery in benign gynecologic disease, but more high quality research is needed to further define the role of robotic surgical systems in this field. 2 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) SAGES notes: Gastrointestinal surgery with the da Vinci Surgical System is safe and comparable to standard laparoscopic approaches, however, surgical outcomes with the da Vinci Surgical System are not superior to laparoscopy. There is insufficient data to know if the oncologic outcomes in surgery using the da Vinci Surgical System are equivalent or superior to conventional laparoscopic surgery. 11 American College of Obstetricians and Gynecologists (ACOG) ACOG and the Society of Gynecological Surgeons state: Patients scheduled for gynecologic procedures of short duration and low complexity are unlikely to benefit from robotic-assisted surgery. They suggest that there is no advantage, and that there are possible disadvantages, to performing the following procedures with robotic assistance compared with other minimally invasive approaches: Tubal ligation Simple ovarian cystectomy Surgical management of ectopic pregnancy Prophylactic bilateral salpingo-oophorectomy 3 Although robotic surgery is being used more for the treatment of cervical cancer, the majority of the studies are retrospective. One study compared robot-assisted hysterectomy with laparoscopic radical hysterectomy found no advantages to the robotic approach. The only area of significance was in a reduced estimate of blood loss among the robotic cohort (115.5 cc versus 171 cc, P<.001). Additional studies are necessary to help validate whether robot-assisted and laparoscopic radical hysterectomy have similar outcomes Additional studies have been done to compare the complications of robotic, laparoscopic and open procedures. Compared to the laparoscopic approach, the robotic surgeries had comparable rates of complications, and the majority of studies were prospective and retrospective Coding Implications Page 2 of 5

3 This clinical policy references Current Procedural Terminology (CPT ). CPT is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2015, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT Codes HCPCS Codes S2900 To numerous to list Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure) ICD-10-CM Codes - Too numerous to list ICD-10-CM Code To numerous to list Reviews, Revisions, and Approvals Date Approval Date Adopted Health Net policy 10/16 Update no revisions 10/17 10/17 References 1. Acar Ö, Işık EÖ, Mut T, et al. Comparison of the trifecta outcomes of robotic and open nephron-sparing surgeries performed in the robotic era of a single institution. Springerplus. Sep 4;4: Advancing Minimally Invasive Gynecology Worldwide (AAGL). AAGL Position Statement: Robotic-Assisted Laparoscopic Surgery in Benign Gynecology. Journal of Minimally Invasive Gynecology, Vol 20, No 1, January/February American College of Obstetricians & Gynecologists (ACOG). Committee Opinion. Robotic Surgery in Gynecology. Number 628, March Chan JK, Gardner AB, Taylor K, et al. Robotic versus laparoscopic versus open surgery in morbidly obese endometrial cancer patients - a comparative analysis of total charges and complication rates. Gynecol Oncol Sep Corrado G, Chiantera V, Fanfani F, et al. Robotic hysterectomy in severely obese patients with endometrial cancer: a multi-centre study. J Minim Invasive Gynecol Sep Hayes. Health Technology Brief. Robotically Assisted Mitral Valve Repair Using the da Vinci Surgical System (Intuitive Surgical Inc.). October 13, Page 3 of 5

4 7. Hayes Medical Technology Directory. Robotically Assisted Stereotactic Radiosurgery (SRS) for Spinal and Extracranial Head and Neck Indications. July 16, Archived Hayes Medical Technology Directory. Robotically Assisted Stereotactic Radiosurgery for Intracranial Indications. June 6, Archived Hayes. Robotically Assisted Stereotactic Radiosurgery for Thoracic and Abdominal Indications. October Archived Paraiso MFR, Falcone T. Robot Assisted Surgery. UpToDate. May 31, Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Safety and Effectiveness Analysis DaVinci Surgical System. July Available at: 12.Soliman PT, Frumovitz M, Sun CC, et al. Radical hysterectomy: a comparison of surgical approaches after adoption of robotic surgery in gynecologic oncology. Gynecol Oncol 2011;123: Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. Health Plan means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan s affiliates, as applicable. The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures. This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time. Page 4 of 5

5 This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This clinical policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan. This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services. Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy. Note: For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs and LCDs should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at for additional information Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene and Centene Corporation are registered trademarks exclusively owned by Centene Corporation. Page 5 of 5

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