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Date Printed: August 22, 2017: 07:02 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-91000-06

Fecha de entrada en vigencia original: 08/15/03

Revisado: 02/23/17

Editado: 03/15/17

Tema: Colonografía por tomografía computarizada (TC) (Colonoscopia virtual)

ESTA GUÍA DE COBERTURA MÉDICA NO ES UNA AUTORIZACIÓN, CERTIFICACIÓN, EXPLICACIÓN DE LOS BENEFICIOS NI GARANTÍA DE PAGO Y NO CONSTITUYE NI SUSTITUYE EL CONSEJO DE UN MÉDICO. TODAS LAS DECISIONES MÉDICAS SON RESPONSABILIDAD EXCLUSIVA DEL PACIENTE Y DEL MÉDICO. LOS BENEFICIOS SE DETERMINAN POR EL CONTRATO DEL GRUPO, EL FOLLETO DE BENEFICIOS DEL ASEGURADO O EL CERTIFICADO DEL SUSCRIPTOR VIGENTE CUANDO SE PRESTARON LOS SERVICIOS. ESTA GUÍA DE COBERTURA MÉDICA APLICA A TODAS LAS LÍNEAS COMERCIALES A MENOS QUE SE INDIQUE LO CONTRARIO EN LA SECCIÓN EXCEPCIONES DEL PROGRAMA.

           
Declaración de posición Facturación/codificación Reembolso Excepciones del programa Definiciones Guías relacionadas
           
Otro Referencias Actualizaciones      
           

DESCRIPCIÓN:

La colonografía por tomografía computarizada (CTC), también conocida como "colonoscopia virtual" es un examen de imagenología mínimamente invasivo del colon y del recto. La CTC usa imágenes adquiridas mediante tomografía computarizada (TC) y técnicas avanzadas de visualización de imágenes bidimensionales (2D) y tridimensionales (3D) para interpretación. Estas imágenes son interpretadas por un radiólogo para determinar la presencia de anomalías en el colon.

DECLARACIÓN DE POSICIÓN:

La colonografía por tomografía computarizada cumple con la definición de necesidad médica para la evaluación diagnóstica cuando la colonoscopia convencional está incompleta o contraindicada:

La colonografía por tomografía computarizada como prueba rutinaria de detección de cáncer de colon no cumple con los criterios descritos arriba para la cobertura y se considera como experimental o en fase de investigación porque no se ha demostrado que los resultados clínicos de una colonografía TC para detección sean superiores a los que se obtienen con otros métodos (por ejemplo, colonoscopia óptica, prueba de sangre oculta en heces o sigmoidoscopia).

A partir del 30 de junio de 2017 la colonografía de CT para la detección del cáncer colorrectal cumple con la definición de necesidad médica para el miembro con riesgo promedio cada 5 años cuando se cumplen TODOS los siguientes criterios *

La colonografía por resonancia magnética (MRC, por sus siglas en inglés) se considera como experimental o en fase de investigación, ya que no hay evidencia clínica suficiente para respaldar el uso de esta tecnología para la detección de cáncer colorrectal rutinaria.

INFORMACIÓN PARA FACTURACIÓN/CODIFICACIÓN:

Se pueden usar los siguientes códigos para describir la colonografía por tomografía computarizada (TC).

Codificación CPT

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

Códigos LOINC

Es posible que la siguiente información sea necesaria para respaldar la necesidad médica: historial clínico y examen físico del médico, notas de evolución del médico, plan de tratamiento y motivo para realizar la colonografía por tomografía computarizada (TC).

Tabla de documentación

Códigos LOINC

Código modificador
LOINC
del período

Descripción de los códigos modificadores LOINC del período

Historia clínica y examen físico

28626-0

18805-2

Incluir todos los datos del tipo seleccionado que representen observaciones realizadas seis meses o menos antes de la fecha de inicio del servicio para el reclamo.

Las notas de consulta del médico tratante (que incluyan el motivo del examen)

18733-6

18805-2

Incluir todos los datos del tipo seleccionado que representen observaciones realizadas seis meses o menos antes de la fecha de inicio del servicio para el reclamo.

Imágenes e informe de la colonoscopia convencional

27895-2

18805-2

Incluir todos los datos del tipo seleccionado que representen observaciones realizadas seis meses o menos antes de la fecha de inicio del servicio para el reclamo.

INFORMACIÓN DE REEMBOLSOS:

Consulte la sección titulada DECLARACIÓN DE POSICIÓN.

El reembolso por la detección asistida por computadora que se usa en la interpretación de la colonografía por tomografía computarizada (TC) (colonoscopia virtual, colonografía TC, CTC) está incluido en el importe permitido de la colonografía por tomografía computarizada (TC) (colonoscopia virtual, colonografía TC, CTC).

EXCEPCIONES DEL PROGRAMA:

La cobertura de los servicios radiológicos mencionados en esta guía que se realicen y facturen en un centro ambulatorio o consultorio se manejarán a través del programa de Gestión Radiológica de BCBSF para productos seleccionados. National Imaging Associates (NIA) determinará la cobertura de estos servicios para productos seleccionados. Consulte los beneficios del contrato del asegurado.

Plan para empleados federales (FEP, Federal Employee Plan): FEP está excluido de la revisión de National Imaging Associates (NIA); apegarse a las directrices del FEP.

Productos Medicare Advantage:

La siguiente Determinación de cobertura local (LCD, Local Coverage Determination) se revisó en la fecha de edición más reciente de la guía: Colonografía por tomografía computarizada, (L33283) ubicada en fcso.com

La siguiente Determinación de cobertura nacional (NCD, National Coverage Determination) se revisó en la fecha de edición más reciente de la guía: Pruebas de detección de cáncer colorrectal, (210.3) ubicada en cms.gov.

DEFINICIONES:

No aplican definiciones específicas a esta guía.

GUÍAS RELACIONADAS:

No corresponde ninguna.

OTROS:

Otros nombres que se usan para informar la Colonografía por tomografía computarizada (colonoscopia virtual):

Colonografía tomográfica computarizada (CTC)

Colonografía TC

Colonografía por tomografía computarizada (CTC)

Colonografía TC tridimensional

REFERENCIAS:

  1. ACR–SAR–SCBT-MR Practice Parameter for the Performance of Computed Tomography (CT) Colonography in Adults, 2014.
  2. Ajaj WM, Lauenstein TC, Pelster G et al. Magnetic resonance colonography for the detection of inflammatory diseases of the large bowel: quantifying the inflammatory activity. Gut 2005; 54: 257-263.
  3. American College of Gastroenterology website; Press release. “Negative Results in New Study Confirm “Virtual” or CT Colonography Not Ready for Clinical Use for Colorectal Cancer Screening”, 12/17/04
  4. American College of Radiology (ACR) Practice Guideline for the Performance of Computed Tomography (CT) Colonography in Adults, 2009.
  5. American College of Radiology ACR Appropriateness Criteria® Colorectal Cancer Screening, 2013.
  6. American Gastroenterological Association (AGA) Institute-Position of the American Gastroenterological Association (AGA) Institute on computed tomographic colonography. Gastroenterology 2006; 131: 1627-1628.
  7. Barish MA, Soto JA, Ferrucci JT. Consensus on current clinical practice of virtual colonoscopy. AJR Am J Roentgenol. 2005 Mar; 184(3): 786-92.
  8. Bibbins-Domingo K, Grossman DC, Curry SJ et al. Screening for Colorectal Cancer US Preventive Services Task Force Recommendation Statement. JAMA 2016; 315 (23): 2564-2575.
  9. Blue Cross Blue Shield Association Virtual Colonoscopy/ Computed Tomography Colonography Medical Policy 6.01.32, 05/15.
  10. Blue Cross Blue Shield Association TEC Assessment – CT Colonography (“Virtual Colonoscopy”) for Colon Cancer Screening, Volume 24, No. 1, August 2009.
  11. Blue Cross Blue Shield Association TEC Assessment – CT Colonography (“Virtual Colonoscopy”) for Colon Cancer Screening, Volume 19, No. 6, July 2004.
  12. Blue Cross Blue Shield Association TEC Assessment –Special Report: Critical Appraisal of CT Colonography Cost-Effectiveness Analyses, Volume 24, No. 2, August 2009.
  13. Centers for Medicare & Medicaid Services National Coverage Determination (NCD) for Colorectal Cancer Screening Tests (210.3), 01/27/14.
  14. Cotton PB, Durkalski VL, Pineau BC, Palesch YY, Mauldin PD, Hoffman B, Vining DJ, Small WC, Affronti J, Rex D, Kopecky KK, Ackerman S, Burdick JS, Brewington C, Turner MA, Zfass A, Wright AR, Iyer RB, Lynch P, Sivak MV, Butler H. Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA. 2004 Apr 14; 291(14): 1713-9.
  15. Davila RE, Rajan E, Baron TH; Standards of Practice Committee, American Society for Gastrointestinal Endoscopy. ASGE guideline: colorectal cancer screening and surveillance. Gastrointest Endosc. 2006 Apr; 63(4): 546-57.
  16. First Coast Services Options, Inc. LCD for Computed Tomographic Colonography (L33283), 10/01/15.
  17. Final Update Summary: Colorectal Cancer: Screening. U.S. Preventive Services Task Force, June 2016.
  18. Halligan S, Altman DG, Taylor SA, Mallett S, Deeks JJ, Bartram CI, Atkin W. CT colonography in the detection of colorectal polyps and cancer: systematic review, meta-analysis, and proposed minimum data set for study level reporting. Radiology. 2005 Dec; 237(3): 893-904.
  19. Hanson ME, Pickhardt Pj, Kim DH. Anatomic factors predictive of incomplete colonoscopy based on findings at CT colonography. American Roentgen Ray Society 2007; 189(4): 774-779.
  20. Heitman SJ, Manns BJ, Hilsden RJ, Fong A, Dean S, Romagnuolo J. Cost-effectiveness of computerized tomographic colonography versus colonoscopy for colorectal cancer screening. CMAJ. 2005 Oct 11; 173(8): 877-81.
  21. Institute for Clinical Systems Improvement (ICSI). Computed Tomographic Colonography for Detection of Colorectal Polyps and Neoplasms. ICSI Technology Assessment Report # 58. Bloomington, MN: ICSI; August 2004.
  22. Johnson, CD, Chen MH, Toledano AY et al. Accuracy of CT colonography for detection of large adenomas and cancers. The New England Journal of Medicine 2008; 359: 1207-1217.
  23. Levin B, Lieberman DA, McFarland B et al. Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer Journal of Clinicians 2008; 58(3): 130-160.
  24. McFarland EG, Levin B, Lieberman et al. Revised colorectal screening guidelines: Joint effort of the American Cancer Society, U.S. Multisociety Task Force on colorectal cancer, and American College of Radiology. Radiology 2008; 248: 717-720.
  25. Mulhall BP, Veerappan GR, Jackson JL. Meta-Analysis: Computed Tomographic Colonography. Ann Intern Med. 2005 Apr 19; 142(8): 635-50.
  26. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) Colorectal Cancer Screening Version. 1.2014.
  27. National Guideline Clearinghouse (NGC). Guideline synthesis: Screening for colorectal cancer. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 1998 Jun (revised 2009 Dec).
  28. National Imaging Associates, Inc. CT (Virtual) Colonoscopy-Diagnostic Clinical Guidelines, 2016.
  29. National Imaging Associates, Inc. CT (Virtual) Colonoscopy-Screening Clinical Guidelines, 2016.
  30. National Institute for Clinical Excellence (NICE). Interventional procedures overview of computed tomography colonography (virtual colonoscopy). London, UK: NICE; August 2004.
  31. Ontario Ministry of Health and Long-Term Care. Computed tomographic colonography (virtual colonoscopy). Toronto: Medical Advisory Secretariat, Ontario Ministry of Health and Long-Term Care (MAS), 2003:49.
  32. Park SH, Ha HK, Kim AY, Kim KW, Lee MG, Kim PN, Shin YM, Byeon JS, Yang SK, Kim JH, Min YI. Flat polyps of the colon: detection with 16-MDCT colonography-preliminary results. AJR Am J Roentgenol. 2006 Jun; 186 (6): 1611-7.
  33. Patwardhan MB, Samsa GP, McCrory DC, Fisher DA, Mantyh CR, Morse MA, Prosnitz RG, Cline KE, Gray RN. Cancer Care Quality Measures: Diagnosis and Treatment of Colorectal Cancer. Evidence Report/Technology Assessment No. 138. (Prepared by the Duke Evidencebased Practice Center under Contract No. 290-02-0025.) AHRQ Publication No. 06-E002. Rockville, MD: Agency for Healthcare Research and Quality. May 2006.
  34. Pickhardt PJ, Choi JR, Hwang I, Butler JA, Puckett ML, Hildebrandt HA, Wong RK, Nugent PA, Mysliwiec PA, Schindler WR. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med. 2003 Dec 4; 349 (23): 2191-200.
  35. Pignone M, Sox HC. Screening guidelines for colorectal cancer: a twice-toal tale. Annals of Internal Medicine 2008; 149(9): 680-682.
  36. Regge D, Laudi C, Galatola G et al. Diagnostic accuracy of computed tomographic colonography for the detection of advanced neoplasia in individuals of increased risk of colorectal cancer. The Journal of the American Medical Association 2009; 301(23): 2453-2461.
  37. Rocky DC, Barish M, Brill JV. et al. CT colonography standards for gastroenterologists for performing and interpreting diagnostic computed tomographic colonography. Gastroenterology 2007; 133: 1005-1024.
  38. Schreyer AG, Rath HC, Kikinis R et al. Comparison of magnetic resonance imaging colonography with conventional colonoscopy for the assessment of intestinal inflammation in patients with inflammatory bowel disease: a feasibility study. Gut 2005; 54(2): 250-256.
  39. Screening for colorectal cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine 2008; 149 (9): 627-637.
  40. Swedish Council on Technology Assessment in Health Care. CT colonography (virtual colonoscopy) – early assessment briefs (Alert). Stockholm: Swedish Council on Technology Assessment in Health Care (SBU), 2004.
  41. U.S. Preventive Services Task Force (USPSTF). Screening for Colorectal Cancer, October 2008.
  42. Wang Z, Liang Z, Li L, Li X, Li B, Anderson J, Harrington D. Reduction of false positives by internal features for polyp detection in CT-based virtual colonoscopy. Med Phys. 2005 Dec; 32 (12): 3602-16.
  43. Whitlock EP, Lin JS, Liles E et al. Screening for colorectal cancer: A targeted, updated systematic review for the U.S. preventive services task force. Annals of Internal Medicine 2008; 149(9): 638-658.
  44. Winawer S, Fletcher R, Rex D, Bond J, Burt R, Ferrucci J, Ganiats T, Levin T, Woolf S, Johnson D, Kirk L, Litin S, Simmang C; Gastrointestinal Consortium Panel. Colorectal cancer screening and surveillance: clinical guidelines and rationale – Update based on new evidence. Gastroenterology. 2003 Feb; 124 (2): 544-60.
  45. YucelC, Lev-Toaff AS, Moussa N et al. CT colonography for incomplete or contraindicated optical colonoscopy in older patients. American Journal of Roentgenology 2008; 190: 145-150.
  46. Zauber AG, Knudsen AB, Rutter CM et al. Technology Assessment-Cost effectiveness of CT colonography to screen for colorectal cancer. Agency for Healthcare Research and Quality Rockville, MD 2009.

APROBACIÓN DEL COMITÉ:

Esta Guía de cobertura médica (MCG, Medical Coverage Guideline) fue aprobada por el Comité de Normas y Coberturas Médicas de BCBSF el 07/28/16.

INFORMACIÓN DE LAS ACTUALIZACIONES DE LA GUÍA:

08/15/03

New Medical Coverage Guideline.

07/01/04

3rd quarter HCPCS coding update; consisting of the addition of 0066T and 0067T.

08/15/04

Scheduled review and revision to guideline; consisting of updated references.

09/15/05

Scheduled review and revision of guideline; consisting of updated references.

09/15/06

Scheduled review and revision of guideline consisting of updated references and added coverage criteria for 0067T.

07/01/07

Updated Program Exception section.

07/15/07

Annual review, coverage and limitations maintained, reformatted guideline, references updated.

01/21/08

Updated Program Exceptions.

05/21/09

Removed Federal Employee Plan (FEP) from BCBSF Radiology Management program exception statement. Added FEP program exception statement: FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

07/01/09

Updated BCBSF Radiology Management program exception; added BlueSelect.

10/15/09

Added, “computed tomographic colonography” to subject. Updated description section. Revised indications for CT colonography. Added experimental or investigational statement for magnetic resonance colonography (MRC). Added Medicare Advantage products program exception. Updated references.

01/01/10

Annual HCPCS coding update: deleted 0066T and 0067T. Added 74261, 74262, and 74263. Revised BCBSF Radiology Management program exception section.

09/15/10

Annual review. Added reimbursement statement for computer-aided detection. Added 74263 (non-covered) to Medicare Advantage program exception. Also, updated references and reformatted some areas of policy.

12/15/11

Annual review; maintain position statements. Updated references.

11/15/12

Position statement revised for clarity. Updated Medicare Advantage products program exception. Deleted Medicare Advantage products ICD-9 codes. Updated references.

05/11/14

Revision: Program Exceptions section updated.

02/15/15

Annual review; revised indications. Updated references.

08/15/16

Annual review; revised program exceptions. Updated references

09/15/16

Revision: Added statement for screening. Updated references.

03/15/17

Revision; revised date for screening CT colonography.

1. Select the procedure.

For Magnetic resonance colonography (MRC), proceed to question #2.

For CT colonography for routine colon cancer screening, proceed to question #3.

For CT colonography, proceed to question #4.

2. Is magnetic resonance colonography (MRC) requested for colorectal cancer screening?

If yes, magnetic resonance colonography (MRC) is considered experimental or investigational.

3. Is CT colonography requested for routine colon cancer screening for any of the following?

• Failed colonoscopy due to medical condition (e.g., hypotension secondary to the sedation, adhesions from prior surgery, excessive colonic tortuosity); OR

• Member is unable to undergo sedation; OR

• Member has a medical condition (e.g., recent myocardial infarction, recent colonic surgery, bleeding disorders, severe lung and/or heart disease, obstructive colorectal cancer)

If yes, meets the medical necessity criteria.

If no, CT colonography for routine colon cancer screening is considered experimental or investigational.

4. Is CT colonography requested for diagnostic evaluation for any of the following when conventional colonoscopy is incomplete or contraindicated?

• Failed colonoscopy due to medical condition (e.g., hypotension secondary to the sedation, adhesions from prior surgery, excessive colonic tortuosity); OR

• Member is unable to undergo sedation; OR

• Member has a medical condition (e.g., recent myocardial infarction, recent colonic surgery, bleeding disorders, severe lung and/or heart disease, obstructive colorectal cancer)

If yes, meets the medical necessity criteria.

If no, CT colonography for diagnostic evaluation is considered experimental or investigational.

Date Printed: August 22, 2017: 07:02 AM