Infrared coagulation (IRC), also called photocoagulation, is used to treat symptomatic first-degree and second-degree internal hemorrhoids. Pulses of infrared radiation are applied to the hemorrhoidal base through a hand-held applicator. These pulses produce a discreet area of necrosis, which heals to form a scar. This reduces or eliminates blood flow through the hemorrhoid, thereby shrinking it, and the mucosa becomes fixed to the underlying tissue. The procedure is easily performed in a physician's office.

Medically Necessary:

Infrared coagulation is considered medically necessary for first-degree or second-degree (i.e., Grade I or Grade II) internal hemorrhoids that are painful or persistently bleeding. A maximum of four treatments within a six-month period are considered medically necessary.

Not Medically Necessary: 

Infrared coagulation is considered not medically necessary for all other indications, including more than four treatments in a six-month period.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Internal hemorrhoids are graded as follows: 

Grade I: Bleeding without prolapse
Grade II: Prolapse with spontaneous reduction (with or without bleeding)
Grade III: Prolapse with manual reduction
Grade IV: Incarcerated, irreducible prolapse

This grading system has been in place for many years and correlates relatively well with treatment algorithms (i.e., Grade I and II hemorrhoids are often successfully treated by nonoperative means while Grade III and Grade IV hemorrhoids are more likely to require surgery).

Infrared coagulation (IRC) is one of several non-surgical treatments for the management of hemorrhoids. The infrared photocoagulator generates infrared radiation that coagulates tissue protein and evaporates water from cells. During this procedure, mechanical pressure and infrared radiation are applied simultaneously to ablate the blood supply to the hemorrhoid. The amount of destruction depends upon the intensity and the duration of application. Usually three to four applications are enough to achieve coagulation of each hemorrhoid. The infrared coagulator is not particularly effective in treating large amounts of prolapsing tissue; therefore it is most beneficial in Grade I and small Grade II hemorrhoids. It has been described to be slightly less painful than rubber band ligation.

The American Society of Colon & Rectal Surgeons practice parameters for the treatment of hemorrhoids note that controlled trials indicate that IRC is useful for first-degree and second-degree hemorrhoids; however, first-degree and second-degree hemorrhoids may need repetitive treatments and alternative methods may be more efficacious (i.e., rubber band ligations). Generally, when additional treatments are necessary, they are one month apart (MacKay, 2001).

Linares and colleagues (2001) prospectively studied the effectiveness of the treatment of internal hemorrhoids with rubber band ligation (RBL) and IRC in 358 individuals with a total of 817 hemorrhoid groups and follow-up period of 36 months. The mean number of hemorrhoids treated per subject was 2.3. RBL was performed with McGown ligator and suction pump, placing the band at the base of the hemorrhoid. IRC was performed with Lumatec coagulation system, applying at least four shoots around each hemorrhoid, with an exposition time ranging between 1 and 1.5 seconds. Treatment was considered effective when individuals became asymptomatic (relief of pain, bleeding, or anal itching) and the obliteration of hemorrhoids after the treatment was confirmed by anal inspection and anoscopy. Of the 358 subjects, 295 were treated with RBL (82.4%). This treatment was effective in 98% of the subjects after 180 days and very good after 36 months. There were 6/295 relapses at 36 months (2%). Those treated with IRC included 63 of 358 subjects (17.6%). In this group, relapses were observed in 6/63 subjects (9.5%) at 36 months, all of them with grade III hemorrhoids that required additional treatment with RBL. The treatment with RBL or IRC depended on the number of hemorrhoids and the hemorrhoidal grade. No significant differences were found regarding the effectiveness between RBL and IRC for the treatment of grade I-II hemorrhoids, while RBL was more effective for grade III and IV hemorrhoids. The authors concluded that RBL and IRC should be considered as good treatments for all grades of hemorrhoids, due to their effectiveness, cost-benefit and small short and long-term morbidity.

Accarpio and colleagues (2002) reported on results of 7850 cases of non-surgical outpatient treatment of hemorrhoids with a combined technique. A combined treatment consisting of sclerotherapy, RBL, and IRC was performed. On the first visit, individuals underwent sclerotherapy to decongest the area and reduce the size of the prolapse, when present. Fifteen days later, rubber band ligation was performed with infrared coagulation on the tissue strangulated by the rubber band. This combined treatment was repeated every 15 days until complete obliteration of all redundant hemorrhoidal tissue was achieved, as well as relief of symptoms. This usually took a total of three treatments; rarely up to seven treatments were necessary.

Gupta (2003) compared infrared coagulation and rubber band ligation (RBL) in terms of effectiveness and discomfort. One hundred individuals with second-degree bleeding hemorrhoids were randomized prospectively to either RBL (N=54) or infrared coagulation (N=46). Parameters measured included postoperative discomfort and pain, time to return to work, relief in incidence of bleeding, and recurrence rate. Pain was assessed using a visual analogue scale from "0" (no pain at all) to "10" (the worst pain ever experienced). Postoperative pain during the first week was stronger in the RBL group (2-5 versus 0-3 on a visual analogue scale). Post-defecation pain and rectal tenesmus was more intense with RBL. The individuals in the infrared coagulation group resumed their duties earlier (2 versus 4 days), but also had a higher recurrence or failure rate. The author concluded that RBL, although more effective in controlling symptoms and obliterating hemorrhoids, is associated with more pain and discomfort. As infrared coagulation can be conveniently repeated in case of recurrence, it could be considered a suitable alternative office procedure for the treatment of early stage hemorrhoids.

Gupta (2007) retrospectively described the results of infrared photocoagulation of Grade I and II bleeding hemorrhoids. Follow up data was collected on 300 individuals for a period of 60 months following treatment with infrared coagulation. Thirty nine individuals had a recurrence of or persistent bleeding. Other post procedure complaints included anal discharge, post defecation discomfort and pruritus. There were no occurrences of septic complications or infections. The author concluded that infrared coagulation for hemorrhoids in early stages is better tolerated than band ligation and could be an easy and effective alternative to conventional treatment.

A literature search from January 2010 to March 2011 resulted in no new published literature that would change the current position.

Peer Reviewed Publications:

1. Accarpio G, Ballari F, Puglisi R, et al. Outpatient treatment of hemorrhoids with a combined technique: results in 7850 cases. Tech Coloproctol. 2002; 6(3):195-196. 
2. Gupta PJ. Infrared coagulation versus rubber band ligation in early stage hemorrhoids. Braz J Med Biol Res. 2003; 36(10):1433-1439.
3. Gupta PJ. Infra red photocoagulation of early grades of hemorrhoids--5-year follow-up study. Bratisl Lek Listy. 2007; 108(4-5):223-226.
4. Johanson JF, Rimm A. Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy. Am J Gastroenterol. 1992; 87(11):1600-1606.
5. Linares Santiago E, Gomez Parra M, et al. Effectiveness of hemorrhoidal treatment by rubber band ligation and infrared photocoagulation. Rev Esp Enferm Dig. 2001; 93(4):238-247. 
6. MacKay D. Hemorrhoids and varicose veins: A review of treatment options. Altern Med Rev. 2001; 6(2):126-140.
7. MacRae HM, Temple LK, McLeod RS. A meta-analysis of hemorrhoidal treatments. Semin C R Surg. 2002; 13:77-83.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Cataldo P, Ellis CN, Gregorcyk S, et al. The Standards Practice Task Force, The American Society of Colon and Rectal Surgeons,USA. Practice parameters for the management of hemorrhoids (revised). Dis Colon Rectum. 2005; 48(2):189-194.Available at: http://www.fascrs.org/files/hemorrhoids_0605.pdf. Accessed on March 04, 2011.
2. Madoff RD, Fleshman JW. Clinical Practice Committee, American Gastroenterological Association.  American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids. Gastroenterology. 2004; 126(5):1463-1473.

1. American Society of Colon & Rectal Surgeons. ASCRS Core Subjects 2005: Hemorrhoids. Peter Cataldo, MD. Available at: http://www.fascrs.org/physicians/education/core_subjects/2005/hemorrhoids/. Accessed on March 04, 2011.

Coagulation, Infrared, of Hemorrhoids
Hemorrhoids, Infrared Coagulation
Infrared Coagulation of Hemorrhoids (IRC)