Virtual colonoscopy, also known as CT colonography, is considered an experimental/investigational procedure. Payment is not made for this procedure. A participating, preferred, or network provider can bill the member for the denied service.

Recently published medical literature provides information on this evolving technology describing promising applications. However, further studies are needed to compare current gold-standard conventional colonoscopy or sigmoidoscopy in low-, average-, and high-risk patient populations.  The use of CT colonography in this overall population-based colon cancer screening strategy has not been clearly defined and has not shown to be cost effective in patient outcomes.

The relatively low specificity and sensitivity of virtual colonoscopy in yielding false positive results reduces its cost-effectiveness, because false positives could result in many unnecessary follow-up conventional procedures. There have been no studies evaluating the effectiveness of CT colonography in reducing morbidity or mortality from colorectal cancer. In addition, there is insufficient data to measure the frequency of complications with CT colonography.

The American Cancer Society’s (ACS) Colorectal Cancer Advisory Group concluded that evidence is insufficient to determine whether CT colonography is comparable or superior in performance to conventional colonoscopic evaluations. The ACS suggested further studies are needed before virtual colonoscopy/CT colonography is recommended for routine colorectal cancer screening.

Codes 0066T and 0067T, as appropriate, should be used to report virtual colonoscopy/CT colonography. However, some providers may report CT of the abdomen (codes 74150-74170) in conjunction with 3-dimensional and/or holographic reconstruction (codes 76376, 76377) to obtain payment. Because CT colonography/virtual colonoscopy is considered investigational, no payment should be made for this procedure under these codes.

Description

CT colonography is often referred to as "virtual colonoscopy."  This test involves pumping air into the colon, and performing a special computed tomographic (CT) study called a helical or spiral CT scan. This type of scan takes many thin pictures of the structures in the abdomen. A computer then constructs 2- and 3-dimensional images of the inside of the colon. This helps the provider detect any abnormalities that may require a closer look.

CT colonography/virtual colonoscopy requires the same type of bowel cleansing regimen prior to the study. However, CT colonography is less invasive than conventional colonoscopy. It does not carry the small but real risk of bowel perforation associated with conventional colonoscopy. It can detect larger polyps, but may not be as sensitive at detecting smaller lesions.

In some instances, virtual colonoscopy may yield a “false positive” reading, that is, a suspicious finding that turns out not to be a polyp. Unlike conventional colonoscopy, polyps cannot be removed during a virtual colonoscopy.  If a suspicious area is noted, a conventional colonoscopy or other procedure may still be necessary to diagnose and/or treat the patient.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Under the Federal Employee Program, all services that utilize FDA-approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient’s condition. Virtual colonoscopy/CT colonography is considered eligible when determined medically necessary based on the patient’s condition.

PRN References

04/2004, CT colonography considered investigational

Computed Tomographic Virtual Colonoscopy to Screen for Colorectal Neoplasia in Asymptomatic Adults, The New England Journal of Medicine, December 2003

The Future of Colorectal Cancer Screening, American Cancer Society New Today, February 2003

Screening for Colorectal Cancer in Adults at Average Risk: A Summary of the Evidence for the U. S. Preventive Services Task Force, Annals of Internal Medicine, July 2002

Cost-effectiveness Analyses of Colorectal Cancer Screening: A Systematic Review for the U. S. Preventive Services Task Force, Annals of Internal Medicine, July 2002

National Blue Cross Blue Shield Medical Policy Reference Manual, 6.01.32, October, 2003