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DESCRIPTIONColonoscopy is a visual examination of the lining of the colon (large intestine, large bowel) with a fiberoptic endoscope. It is inserted through the anus and rectum and advanced through the large intestine under direct vision, using the scope's optical system. Instruments and tools can be passed through the scope, for taking samples (biopsies). This procedure may be performed in the outpatient setting.
Flexible sigmoidoscopy is a visual examination of the rectum and lower colon called the sigmoid colon. A sigmoidoscope, long flexible tube with fiber optics, is passed through the anus and rectum into the sigmoid colon. Instruments and tools can be passed through the scope, for taking samples (biopsies). This procedure may be performed in the outpatient setting.
Virtual colonoscopy, also known as computed tomography (CT) colonography, is an imaging technique of the colon involving thin-section helical CT to generate high-resolution 2-dimensional axial images of the colon. Three-dimensional images, which resemble the endoluminal images obtained with conventional endoscopic colonoscopy, are then reconstructed off line. Virtual colonoscopy has been investigated as an alternative to conventional endoscopic colonoscopy, specifically as an alternative screening technique for colon cancer. While virtual colonoscopy requires a full bowel preparation, similar to conventional colonoscopy, no sedation is required, and the examination is less time consuming. However, gas insufflation of the intestine, which may be uncomfortable to the patient, and interpretation of the images is described as difficult and time consuming.
POLICYFor Coding Guidelines see the Monitored Anesthesia Care during Gastrointestinal Endoscopy Policy.
Screening (asymptomatic individuals) colonoscopy, fecal occult blood test (FOBT) and sigmoidoscopy will be allowed under the following guidelines:
Beginning at age 50, both men and women should follow ONE of the screening options below:
A digital rectal examination (DRE) should be performed at the time of EACH screening sigmoidoscopy or colonoscopy.High Risk
People should begin colorectal cancer screening earlier and/or undergo screening more often if they have any of the following colorectal cancer risk factors. Frequency should be determined by the ordering physician:
Inflammatory Bowel Disease
Most patients do not require colonoscopy for initial diagnosis, unless clinical sigmoidoscopy and radiological studies fail to secure diagnosis. Multiple biopsies are helpful when it is clinically necessary to distinguish between ulcerative colitis and Crohn's. Screening colonoscopy for follow-up of inflammatory bowel disease is usually not covered except for cancer surveillance in chronic ulcerative colitis.
Abnormal Exam (Symptomatic individuals)
Colonoscopy is considered medically necessary under the following circumstances:Unexplained bleeding
Flexible sigmoidoscopy in the ambulatory or office-setting is considered medically necessary under the following circumstances:
Computed tomography (CT) colonography, commonly referred to as virtual colonoscopy, may be considered medically necessary in patients for whom a conventional colonoscopy is indicated but who are unable to undergo conventional colonoscopy for medical reasons or in patients with an incomplete conventional colonoscopy because of colonic stenosis or obstruction.
Except as noted in the policy statement above, CT colonography is considered not medically necessary for the purposes of colon cancer screening because the clinical outcomes with this screening strategy have not been shown to be superior to other approaches including optical colonoscopy.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Computed tomography (CT) colonography should be performed with a minimum 16-row detector CT scanner.
Contraindications to conventional colonoscopy may include continuous anticoagulation therapy or high anesthesia risk.
POLICY HISTORY2/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/1999: Updated to reflect national standards
2/2001: Reviewed by MPAC; Virtual colonoscopy considered investigational. Healthy you guidelines will be aligned to be consistent with the American Cancer Society recommendations for early colorectal cancer detection.
5/23/2001: Code reference section revised; ICD-9 diagnosis code 235.2 and 239.0 deleted
11/14/2001: Colonoscopy and flexible sigmoidoscopy description revised under the "Description" section.
2/13/2002: Investigational definition added
3/20/2002: Revised verbiage of familial syndromes for clarity
3/26/2002: Healthy You guideline for barium enema deleted; G0121 added to non-covered
3/27/2002: Healthy You guidelines moved to Policy Exceptions
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 235.2 and 239.0 added
7/23/2002: Policy section revised, Policy Exceptions deleted
7/30/2002: Prior authorization deleted
8/22/2002: CPT codes 44390-44397, 45332-45345, 45382-45387 deleted; ICD-9 procedure codes 45.42-45.43 deleted; ICD-9 diagnosis codes 555.9, 787.99, 799.8 deleted; ICD-9 diagnosis codes 557.1- 557.9 added; ICD-9 diagnosis code 564.89 description revised and one deleted; ICD-9 diagnosis code 556.9 is covered and non-covered depending on the description
12/11/2002: HCPCS G0102 added
11/18/2004: Reviewed by MPAC, CT colonography (“virtual colonoscopy”) remains investigational, policy title “Colonoscopy and Flexible Sigmoidoscopy” renamed “Colonoscopy, Flexible Sigmoidoscopy, and CT Colonography,” Description section updated to be consistent with BCBSA policy # 6.01.32, Sources updated
4/12/2005: Code Reference section updated, CPT code 44390, 44392, 44393, 44394, 45307, 45332, 45333, 45338, 45339, 45383, 45384, 45385 added covered codes, ICD-9 procedure code 45.42, 45.43, 98.03, 98.04 added covered codes, ICD-9 diagnosis 560.89 added covered codes, ICD-9 diagnosis codes 578.1 description revised covered codes, HCPCS G0102 deleted covered codes, HCPCS G0328 added covered codes, HCPCS 0066T, 0067T added non-covered codes, ICD-9 diagnosis code 556.9, 562.11, 562.13, 567.9, 569.49, 569.83, V72.83 deleted non-covered codes
3/13/2006: Coding updated. CPT4 2006 revisions added to policy
3/21/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
12/27/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated. CPT/HCPCS 2008 revisions added to policy
7/8/2008: Anesthesia Coding Policy hyperlink added
9/15/2008: Code reference section updated per the annual ICD-9 updates effective 10-1-2008
9/29/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. HCPC code G0107 deleted from covered table due to code was deleted as of 12-31-06.
04/12/2010: Policy Statement revised to include CT Colonography may be considered medically necessary in patients with medical reasons. Code Reference Section updated revised to identify deleted codes S0605, 0066T and 0067T. Added new CPT Code 74261 and 74262 to the Covered Codes Table and CPT Code 74263 to Non-Covered Codes Table.
07/12/2012: Policy reviewed; no changes to policy statement. Removed S0605, 0066T, and 0067T from the Code Reference section as these codes have been deleted.
05/08/2013: Policy reviewed; no changes.
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 44388, 44390, 44392, 45330, 45332, 45333, 45378, 45379, 45384, and 45385. Effective 1/1/15. Added the following new 2015 CPT codes: 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 45346, 45347, 45349, 45350, 45388, 45389, 45390, 45393, 45398, and 45399. Added the following new 2015 HCPCS codes to the Code Reference section: G6019, G6020, G6022, G6023, G6024, G6025.
08/25/2015: Code Reference section updated for ICD-10.
12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to remove deleted CPT codes 44393, 45339, 45355, and 45383.
SOURCE(S)Hayes Medical Technology Directory
American Society of Gastroendoscopy (ASGE) consensus statement, "The Appropriate Use of Gastrointestinal Endoscopy"
Guidelines for Clinical Applications by the ASGE; Publication Nos. 1009 and 1013 1986.
United States Preventive Services Task Force (USPSTF) 1996 recommendation
American Cancer Society, Colon and Rectum Cancer Resource Center recommendations for early colorectal cancer detection
TEC Assessment Program, Volume 19, No. 6, July 2004
Blue Cross Blue Shield association policy #6.01.32
CODE REFERENCEThis is not intended to be a comprehensive list of codes. Note that some codes may be variable and coverage will be based on the clinical indication for the service.
For Coding Guidelines see the Anesthesia Coding Policy .
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.