LARGE INTESTINE CANCER - WITH DISTANT METASTASIS OR INOPERABLE, UNRESECTABLE OR RECURRENT

Colon Cancer; Colon Carcinoma; Colorectal Cancer; Colorectal Carcinoma; Rectal Cancer; Rectal Carcinoma; Large Bowel Cancer; Large Bowel Carcinoma; Large Intestine Adenocarcinoma; Colon Adenocarcinoma

Large Intestine Cancer forms in the tissues of the colon. Most colon cancers are adenocarcinomas. When Large Intestine Cancer spreads outside the colon or rectum, cancer cells are often found in nearby lymph nodes. If cancer cells have reached these nodes, they may also have spread to other lymph nodes or other organs. Large Intestine Cancer cells most often spread to the liver.

Large Intestine Cancer is more likely to occur as people age. More than 90% of diagnoses are made after age 50 and the average age at diagnosis is 72.

Diagnostic testing: The following may be used to diagnose the disease:

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  Fecal occult blood test (FOBT);

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  Sigmoidoscopy;

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  Colonoscopy;

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  Double-contrast barium enema; or

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  Digital rectal exam.

The following tests and procedures may be used to determine if the Large Intestine Cancer has spread:

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  CT scan, lymph node biopsy;

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  Carcinoembryonic antigen (CEA) assay;

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  MRI; or

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  Surgery.

In the absence of these reports, the adjudicator may use a physician's opinion that indicates the cancer is inoperable or unresectable based on described objective findings.

Physical findings: Some signs and symptoms of Large Intestine Cancer include:

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  Changes in bowel habits, including diarrhea or constipation or a change in consistency of stool that lasts longer than four weeks;

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  Rectal bleeding or blood in stool;

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  Persistent abdominal discomfort, such as cramps, gas, or pain;

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  A feeling that your bowel doesn’t empty completely;

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  Weakness or fatigue; and

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  Unexplained weight loss.

Many people experience no symptoms in the early stages of the disease. When symptoms appear, they will likely vary, depending on the cancer’s size and location in the large intestine.

ICD-9: 153.9, 154.8, 230.3, 230.4, 795.81

Large Intestine Cancer is the second leading cause of death from cancer in the United States. Inoperable or unresectable cancer of the Large Intestine may progress locally and cause intestinal obstruction, uncontrolled GI bleeding, or severe pain from invasion into the sacral nerve plexus.

Surgical resection is the mainstay of treatment, and may be followed by chemotherapy. Approximately 50% of patients are cured with surgery.

Suggested MER for Evaluation:

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  A pathology report and an operative report are the preferred methods for documentation;

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  Clinical note from a surgeon that the cancer is inoperable; and

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  Surgical pathology report that the cancer was not completely removed and that the surgical margins were positive for malignancy.

“Inoperable” refers to a physician's opinion that surgery would not be beneficial based on a review of imaging studies, laboratory results, and physical examination findings.

“Unresectable” cancer is established when the operative report indicates that the cancer is not completely removed or the pathology report notes that the surgical specimen has positive margins.

Suggested Listings for Evaluation:

Satisfies the criteria in 13.18 A with clinical note stating tumor is inoperable or pathology report or operative note indicating tumor was unresectable or had positive surgical margin.

Satisfies the criteria in 13.18 C if metastases beyond the regional lymph nodes.