Effective Dates: 10/05/2023 - Present Previous | Next

TN 60 (10-23)

DI 23022.325 Small Intestine Cancer - with Distant Metastases or Inoperable or Recurrent

COMPASSIONATE ALLOWANCES INFORMATION

SMALL INTESTINE CANCER - WITH DISTANT METASTASES OR INOPERABLE OR RECURRENT
ALTERNATE NAMES Small Intestine Adenocarcinoma; Small Intestine Sarcoma; Small Intestine Gastrointestinal Stromal Tumor; Small Intestine Carcinoid; Small Intestine Carcinoma

DESCRIPTION

Small Intestine Cancer forms in tissues of the small intestine. The most common type is adenocarcinoma. Most of these tumors occur in the part of the small intestine near the stomach. They may grow and block the intestine.

DIAGNOSTIC TESTING, PHYSICAL FINDINGS, AND ICD-9-CM/ICD-10-CM CODING

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

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    Physical exam and history;

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    Laboratory tests;

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    X-rays;

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    Barium enema;

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    Fecal occult blood test (FOBT);

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    Endoscopy;

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    Biopsy;

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    CT scan; and/or

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    Surgery.

Physical findings: Physical findings for small intestine cancer may include:

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    Blood in the stool (feces);

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    Dark/black feces;

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    Diarrhea;

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    A lump in the abdomen;

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    Pain or cramps in the abdomen;

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    Unexplained weight loss; and

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    Episodes of abdominal pain that may be accompanied by severe nausea or vomiting.

ICD-9: 152

ICD-10: C78.4
PROGRESSION The overall 5-year survival rate for resectable adenocarcinoma is only 20%.

TREATMENT

Treatment may include surgery, radiation, biologic therapy, and/or chemotherapy.

SUGGESTED PROGRAMMATIC ASSESSMENT*

Suggested MER for Evaluation:
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    A pathology report;

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    An operative report; or

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    A physician's opinion that indicates the cancer is inoperable or unresectable based on described objective findings.

“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:
DETERMINATION

LISTING

 REMARKS
Meets 13.17 Small Intestine Cancer that is inoperable, unresectable, recurrent, or with distant metastases meets the criteria in listing 13.17.
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* Adjudicators may, at their discretion, use the Medical Evidence of Record or the listings suggested to evaluate the claim. However, the decision to allow or deny the claim rests with the adjudicator.
To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0423022325
DI 23022.325 - Small Intestine Cancer - with Distant Metastases or Inoperable or Recurrent - 10/05/2023
Batch run: 10/05/2023
Rev:10/05/2023