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Date Printed: June 26, 2017: 01:25 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

Original Effective Date: 08/15/03

Reviewed: 02/23/17

Revised: 03/15/17

Subject: Computed Tomographic (CT) Colonography (Virtual Colonoscopy)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates  
           

DESCRIPTION:

Computed tomographic colonography (CTC), also known as "virtual colonoscopy," is minimally invasive imaging examination of the colon and rectum. CTC uses CT acquired images and advanced 2-dimensional (2D) and 3-dimensional (3D) image display techniques for interpretation. These images are interpreted by a radiologist to determine the presence of abnormalities of the colon.

POSITION STATEMENT:

CT colonography meets the definition of medical necessity for diagnostic evaluation for 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)

CT colonography for the purpose of routine colon cancer screening that does not meet the above criteria for coverage is considered experimental or investigational because the clinical outcomes of CT colonography for screening have not been shown to be superior to other approaches (e.g., optical colonoscopy, fecal occult blood testing, or sigmoidoscopy)

Effective July 1, 2017 CT colonography for colorectal cancer screening meets the definition of medical necessity for average risk member every 5 years when ALL of the following criteria* are met:

50-75 years of age; AND

Asymptomatic; AND

Without any of the following:

A family history of known genetic disorders that predispose them to a high lifetime risk of colorectal cancer (such as Lynch syndrome or familial adenomatous polyposis); OR

A personal history of inflammatory bowel disease; OR

A previous adenomatous polyp; OR

A previous history of colorectal cancer

* Member selection criteria are based on the U.S. Preventive Services Task Force recommendation.

Magnetic resonance colonography (MRC) is considered experimental or investigational, as there is insufficient clinical evidence to support the use of this technology for routine colorectal cancer screening.

BILLING/CODING INFORMATION:

The following codes may be used to describe computed tomographic (CT) colonography.

CPT Coding:

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

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for computed tomographic (CT) colonography.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician visit note (to include reason for the examination)

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Conventional colonoscopy images and report

27895-2

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

Reimbursement for computer-aided detection used in the interpretation of computed tomographic (CT) colonography (virtual colonoscopy, CT colonography, CTC) is included in the allowance of the computed tomographic (CT) colonography (virtual colonoscopy, CT colonography, CTC).

PROGRAM EXCEPTIONS:

Coverage for the radiology services referenced in this guideline performed and billed in an outpatient or office location will be handled through the BCBSF Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to member's contract benefits.

Federal Employee Plan (FEP): FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Computed Tomographic Colonography, (L33283) located at fcso.com.

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Colorectal Cancer Screening Tests, (210.3) located at cms.gov.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report Computed tomographic colonography (virtual colonoscopy):

Computed tomography colonography (CTC)

CT colonography

Computed tomographic colonography (CTC)

Three-dimensional CT colonography

REFERENCES:

  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. 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.
  14. 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.
  15. Final Update Summary: Colorectal Cancer: Screening. U.S. Preventive Services Task Force, June 2016.
  16. 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.
  17. 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.
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. Mulhall BP, Veerappan GR, Jackson JL. Meta-Analysis: Computed Tomographic Colonography. Ann Intern Med. 2005 Apr 19; 142(8): 635-50.
  24. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ®) Colorectal Cancer Screening Version. 1. 2016.
  25. 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).
  26. National Imaging Associates, Inc. CT (Virtual) Colonoscopy-Diagnostic Clinical Guidelines, Jan 2017.
  27. National Imaging Associates, Inc. CT (Virtual) Colonoscopy-Screening Clinical Guidelines, Jan 2017.
  28. National Institute for Clinical Excellence (NICE). Interventional procedures overview of computed tomography colonography (virtual colonoscopy). London, UK: NICE; August 2004.
  29. 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.
  30. 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.
  31. 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.
  32. 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.
  33. Pignone M, Sox HC. Screening guidelines for colorectal cancer: a twice-toal tale. Annals of Internal Medicine 2008; 149(9): 680-682.
  34. 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.
  35. 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.
  36. 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.
  37. Screening for colorectal cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine 2008; 149 (9): 627-637.
  38. 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.
  39. U.S. Preventive Services Task Force (USPSTF). Screening for Colorectal Cancer, June 2016.
  40. 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.
  41. 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.
  42. 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.
  43. 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.
  44. 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.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/23/17.

GUIDELINE UPDATE INFORMATION:

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.

DECISION TREE:

Date Printed: June 26, 2017: 01:25 AM