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Medical Policy: 06.01.18
Original Effective Date: March 2002
Reviewed: August 2011
Revised: January 2009
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Virtual colonoscopy, also known as CT colonography, is an imaging technique of the colon involving thin-section helical computed tomography to generate high-resolution two-dimensional axial images of the colon. Three-dimensional images, which resemble the endoluminal images obtained with conventional endoscopic colonoscopy, are then reconstructed off line. While virtual colonoscopy does require a full bowel preparation, similar to conventional colonoscopy, no sedation is required and the exam is less time-consuming. However, gas insufflation of the intestine, which may be uncomfortable to the patient, is required and interpretation of the images has been described as difficult and time consuming.
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Prior Approval:
Not applicable
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Policy:
Screening CT colonoscopy may be considered medically necessary:
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Once every 5 years for patients 50 years of age or older who are unable, due to an accompanying medical conditions, to undergo screening optical colonoscopy, or who have failed optical colonoscopy
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Once every 5 years for patients younger than 50 years of age who are unable, due to an accompanying medical condition, to undergo screening optical colonoscopy, or who have failed optical colonoscopy and are at increased risk for colorectal cancer or polyps due to one of the following:
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Strong family history of colorectal cancer or polyps in a first-degree relative younger than 60
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Two or more first degree relatives of any age with a history of colorectal cancer or polyps
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Known family history of colorectal cancer syndromes such as familial adenomatous polyposis [FAP] or hereditary nonpolyposis colon cancer [HNPCC]
Diagnostic CT colonoscopy may be considered medically necessary:
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When optical colonoscopy is incomplete due to inability to pass the colonoscope because of an obstructing rectal or colon lesion, stricture, scarring from previous surgery, tortuosity, redundancy, or severe diverticulitis: OR
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When the patient is receiving chronic coagulation that cannot be interrupted; OR
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When patient is unable to tolerate optical colonoscopy or associated sedation due to cardiac, pulmonary, or neuromuscular comorbidities
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material
- 74262 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed
- 74263 Computed tomographic (CT) colonography, screening, including image postprocessing
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Selected References:
- Johnson CD, Harmsen WS, Wilson LA, et al. Prospective blinded evaluation of computed tomographic colonography for screen detection of colorectal polyps. Gastroenterology. 2003 Aug; 125(2): 311-9.
- Cotton PB, Durkalski VL, Pineau BC, et al. Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA. 2004;291: 1713–1719.
- Landeras LA Aslam R Yee J Virtual Colonoscopy: Technique and Accuracy.
Radiol Clin North Am. 2007 Mar;45(2):333-345.
- 2004 TEC Assessment: CT Colonography (“Virtual Colonoscopy”) for Colon Cancer ScreeningNICE: Computed tomographic colonography (virtual colonoscopy). June 2005.
- ECRI Institue TARGET Evidence Report 10/2007: Computed tomographic (CT) colonography for colorectal cancer detection in asymptomatic and symptomatic patients.
- ECRI Institute. Overview: Imaging services. Health Technology Forecast 10/2007.
- Johnson CD, Chen MH, Toledano AY et al. Accuracy of CT Colonography for Detection of Large Adenomas and Cancers. N Engl J Med. 2008 Sep 18;359(12):1207-17.
- Whitlock EP, Lin JS, Liles E et al. Screening for colorectal cancer: a targeted, updated systematic review for the U.S. Preventative Services Task Force. Ann Intern Med. 2008 Nov 4;149(9):638-58. Epub 2008 Oct 6.
- Graser A, Stieber P, Nagel D et al. Comparison of CT Colonography, Colonoscopy, Sigmoidoscopy, and Fecal Occult Blood Tests for the Detection of Advanced Adenoma in an Average Risk Population. Gut. 2008 Oct 13.
- Pickhardt PJ, Hassan C, Laghi A et al. Clinical management of small (6- to 9-mm) polyps detected at screening CT colonography: a cost-effectiveness analysis. AJR Am J Roentgenol. 2008 Nov;191(5):1509-16.
- Imperiale TF, Glowinski EA, Lin-Cooper C et al. Five-Year Risk of Colorectal Neoplasia after Negative Screening Colonoscopy. N Engl J Med 2008 Sep 18;358(12):1218-24.
- Berland LL. Incidental extracolonic findings on CT colonography: the impending deluge and its implications. J Am Coll Radiol. 2009 Jan;6(1):14-20.
- Summers RM, Frentz SM, Liu J et al. Conspicuity of colorectal polyps at CT colonography: visual assessment, CAD performance, and the important role of polyp height. Acad Radiol. 2009 Jan;16(1):4-14.
- Liang Z, Richards R. Virtual colonoscopy vs optical colonoscopy. Expert Opin Med Diagn. 2010 March 1; 4(2): 159-69. doi:10.1517/17530051003658736.
- Pickhardt PJ, Kim DH, Meiners RJ et al. Colorectal and extracolonic cancers detected at screening CT colonography in 10,286 asymptomatic adults. Radiology. 2010 Apr; 255(1): 83-8.
- Lin OS. Computed tomographic colonography: hope or hype? World J Gastroenterol. 2010 Feb 28; 16(8):915-20.
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Policy History:
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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