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.

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

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.

1.     Effective 03/01/2017: Added indication for screening based on USPSTF recommendations. Pre-authorization is required.