CT Colonography, also known as virtual colonoscopy (codes 74261, 74262), is considered eligible when medically indicated for patients who cannot tolerate an endoscopic colonoscopy. Examples of these conditions include:

• an incomplete standard endoscopic colonoscopy of the entire colon due to the inability to pass the colonoscope proximally;
• an obstructing neoplasm, spasm, redundant colon, extrinsic compression, or aberrant anatomy/scarring from prior surgery;
• complications from a previous standard colonoscopy;
• increased sedation risk (for example, COPD, previous anesthesia adverse reaction);
• diverticulitis with increased risk of perforation.

CT colonography for all other clinical indications is considered not medically necessary. A participating, preferred or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

CT colonography is not covered when performed as a screening procedure (code 74263) to evaluate asymptomatic patients (patients without signs and/or symptoms of disease or illness). In this case, a participating, preferred, or network provider can bill the member for the non-covered service.

Description

CT colonography is often referred to as "virtual colonoscopy." This diagnostic imaging technique for visualizing the colon can be used as an alternative to conventional endoscopic colonoscopy for certain conditions. It involves insufflation of the colon to perform a special computed tomographic (CT) study called a helical or spiral CT scan.

CT colonography takes many high-resolution, thin pictures of the structures in the abdomen. A computer then uses the acquired image data to reconstruct 2- and 3-dimensional images of the inside of the colon. The resulting images resemble the endoluminal images obtained with conventional endoscopic colonoscopy. This helps the provider detect any abnormalities that may require a closer look.

Similar to conventional colonoscopy, CT colonography requires the full bowel preparation or cleansing regimen prior to the study. However, CT colonography generally requires no sedation, is less invasive, and less time consuming. 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.

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. CT colonography/virtual colonoscopy is considered eligible when determined medically necessary based on the patient’s condition.

National Blue Cross Blue Shield Technology Assessment, March 2005

American College of Radiology Practice Guidelines for the Performance of Computed Tomography (CT) Colonography in Adults, October 2005

Guidelines: Technology Status Evaluation Report, Gastrointestinal Endoscopy, April 2003

CT Colonography for Colon Cancer Screening, Gastrointestinal Endoscopy, January 2006

Multislice CT Colonography: Current Status and Limitations, Radiologic Clinics of North America, November 2005

The Emerging Role of Virtual Colonoscopy, The Medical Clinics of North America, January 2005

CT Colonography: Unraveling the Twists and Turns, Current Opinion in Gastroenterology, January 2005

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 2006

American Gastroenterological Association (2008)

American College of Radiology Appropriateness Criteria (2006)

Pignone M, Sox HC. Screening Guidelines for Colorectal Cancer: A Twice-Told Tale. Ann Intern Med. 2008;149(9):680-682.

Pearson SD, Knudsen AB, Scherer RW, Weissberg J, Gazelle GS. Assessing the Comparative Effectiveness of a Diagnostic Technology: CT Colonography. Health Affairs. 2008;27(6):1503-1514.

Johnson CD, Chen M-H, Toledano AY, Heiken JP, et al. Accuracy of CT Colonography for Detection of Large Adenomas and Cancers. N Engl J Med. 2008;359(12):1207-1217.

Yucel C, Lev-Toaff AS, Moussa N, Durrani H. CT Colonography for Incomplete or Contraindicated Optical Colonoscopy in Older Patients. AJR. 2008;190:145-150.

Kim DH, Pickhardt PJ, Taylor AJ, Leung WK, et al. CT Colonography versus Colonoscopy for the Detection of Advanced Neoplasia. New Engl J Med. 2007;357(14):1403-1412.

United States Preventive Services Task Force (USPSTF)(2008)

Agency for Health Care Research and Quality (AHRQ)(2009)