Coverage Policies

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Current policies effective through April 30, 2024.

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INDEX:



Effective Date: 01/01/2006	Title: Virtual Colonscopy
Revision Date: 03/01/2017	Document: BI148:00
CPT Code(s): 74261-74263
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. Virtual colonoscopy uses CT technology to produce virtual images of the bowel. It is intended to eliminate the need for mechanical sigmoidoscopy or colonoscopy. This technique has not been demonstrated to be better than other techniques except in certain specific circumstances. For this reason, QualChoice will cover virtual colonoscopy only with pre-authorization.
Medical Statement
1. Virtual colonoscopy (also known as three-dimensional computed tomographic (CT) colonography, CT colonography) is considered medically necessary for colonic evaluation of symptomatic members with a known colonic obstruction or an incomplete colonoscopy due to obstructive or stenosing colonic lesions, or in members who are unable to undergo standard diagnostic or screening sigmoidoscopy or colonoscopy because of a contraindication or intolerance. 2. Virtual CT colonoscopy is considered experimental and investigational for all other indications, including evaluation of inflammatory bowel disease or for persons without an obstruction or incomplete colonoscopy. 3. Virtual colonoscopy using magnetic resonance imaging (MRI) (also known as MRI colonography) is considered experimental and investigational for the screening or diagnosis of colorectal cancer, inflammatory bowel disease, or other indications because its value for these indications has not been established. Codes Used In This BI: 74261 CT colonography, diagnostic 74262 CT colonography w/dye, diagnostic 74263 CT colonography, screening
Background
Three-dimensional computed tomographic (CT) colonography, or “virtual colonoscopy,” is a promising new imaging method. The technique combines the use of rapid helical CT with computer software capable of rendering images of the whole colon. Using a conventional workstation and a dynamic display of images, a radiologist conducts virtual examinations of the bowel, simulating the way endoscopists view the colon. This method is being promoted by some as a noninvasive screening test for colorectal neoplasia. The current cost of virtual colonoscopy probably prohibits its use as a screening tool. A major component of the cost is the time now required for a radiologist to perform the procedure. An appreciable number of patients undergoing virtual colonoscopy screening would need a subsequent colonoscopy and biopsy to confirm the diagnosis and to resect polyps. The need for a follow up colonoscopy must be included in any cost-effectiveness analysis of screening with virtual colonoscopy. The relatively low specificity of virtual colonoscopy in most series (i.e., the many false positive results) reduces its cost-effectiveness, because falsely positive results lead to many unnecessary follow-up conventional colonoscopies. A study by Cotton, et al. (2004) reported that the accuracy of CT colonography (virtual colonoscopy) for the detection of colorectal cancer is less reliable than previously thought. The sensitivity of CT colonography for detecting one or more lesions sized at least 6 mm was 39 % and for lesions sized at least 10 mm, it was 55 %. These results were significantly lower than those for conventional colonoscopy, with sensitivities of 99 % and 100 %, respectively. The authors stated that “even if the results of CT colonography continue to be good in the hands of experts, it has yet to be proven that this expertise can be taught and disseminated reliably into daily practice”. The authors concluded that CT colonography is not yet ready for widespread clinical application; techniques and training need to be improved. More recently, Rockey (2010) stated that “available data suggest that CT colonography, although a viable colon cancer screening modality in the United States, is not ready for widespread implementation, largely because of the lack of standards for training and reading and the limited number of skilled readers.”
Reference
1. 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(14):1713-1719. 2. Rex DK; ACG Board of Trustees. American College of Gastroenterology action plan for colorectal cancer prevention. Am J Gastroenterol. 2004; 99(4):574-577. 3. BlueCross BlueShield Association (BCBSA), Technology Evaluation Center (TEC). CT colonography (“virtual colonoscopy”) for colon cancer screening. TEC Assessment Program. Chicago, IL: BCBSA; July 2004; 19(6). Available at: http://www.bcbs.com/tec/vol19/19_06.html. 4. Van Dam J, Cotton P, Johnson CD, et al. AGA future trends report: CT-Colonography. Gastroenterology. 2004; 127(3):970-984. 5. Winawer SJ. Screening of colorectal cancer: Progress and problems. Recent Results Cancer Res. 2005; 166:231-244. 6. Van Gelder RE, Florie J, Stoker J. Colorectal cancer screening and surveillance with CT colonography: Current controversies and obstacles. Abdom Imaging. 2005; 30(1):5-12. 7. Danish Centre for Evaluation and Health Technology Assessment (DACEHTA). Colon examination with CT colonography. A health technology assessment. Summary. Danish Health Technology Assessment -- grant funded projects 2005; 5(3). Copenhagen, Denmark: National Board of Health; 2005. 8. Mulhall BP, Veerappan GR, Jackson JL. Meta-analysis: Computed tomographic colonography. Ann Intern Med. 2005; 142(8):635-650. 9. Imperiale TF. Can computed tomographic colonography become a “good” screening test? Ann Intern Med. 2005; 142(8):669-670. 10. National Institute for Health and Clinical Excellence (NICE). Computed tomographic colonoscopy (virtual colonoscopy). London, UK: NICE; June 2005. Available at: http://www.nice.org.uk/pdf/ip/IPG129guidance.pdf 11. Aetna Clinical Policy Bulletins; Virtual Colonoscopy at: http://www.aetna.com/cpb/data/CPBA0535.html 12. Hayes Medical Technology Assessment; Computed Tomography Colonography (Virtual Colonoscopy) Jan. 14, 2006 13. Hayes Medical Technology Assessment; Computed Tomography Colonography March 13, 2008, updated June 24, 2011 14. Arkansas BlueCross BlueShield Coverage Policy Manual; Virtual Colonoscopy/CT colonography. At: http://www.arkbluecross.com/members/ex_report.asp?ID=2002020 15. Rockey, DC. Computed tomographic colonography: ready for prime time? Gastroenterol Clin North Am. 2010 Dec; 39(4):901-9 16. USPSTF. Screening for Colorectal Cancer, USPSTF Recommendation Statement. JAMA. 2016; 315(23):2564-2575. Addendum: 1. Effective 03/01/2017: Added indication for screening based on USPSTF recommendations. Pre-authorization is required.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

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