CT (Virtual) Colonoscopy (ARCHIVED)

Policy ID: X-52-021

Section: Radiology

Effective Date: July 01, 2018

Revised Date: March 07, 2024

Revision Effective Date: May 06, 2024

Last Reviewed: March 19, 2024

Applies To: Commercial and Medicaid Expansion

This policy has been Archived effective May 06, 2024. Click the Archive tab above for more information.

Policy ID: X-52-020

Section: Radiology

Effective Date: July 01, 2018

Revised Date: November 15, 2019

Last Reviewed: January 26, 2023

Archived Date: May 06, 2024

Applies To: Commercial and Medicaid Expansion

Description

Computed tomographic (CT) colonography, also referred to as virtual colonoscopy, is used to examine the colon and rectum to detect abnormalities such as polyps and cancer. In addition to its use as a diagnostic test in symptomatic individuals, CT colonography may be used in asymptomatic individuals with a high risk of developing colorectal cancer.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

CT colonoscopy (virtual colonoscopy) may be considered medically necessary for diagnostic evaluation when conventional colonoscopy is contraindicated for ANY of the following indications:

Individual had failed colonoscopy due to conditions such as hypotension secondary to the sedation; adhesions from prior surgery; excessive colonic tortuosity; or
Individual has obstructive colorectal cancer; or
Individual is unable to undergo sedation or has medical conditions, (e.g., recent myocardial infarction, recent colonic surgery, bleeding disorders, severe lung and/or heart disease).

CT colonoscopy (virtual colonoscopy) for all other indications is considered not medically necessary.

Procedure Codes

74261

74262

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019 HMK archived - review by Evicore. Keep our current? (Yes) (if unable to perform optical colonoscopy e.g., high risk, obstruction, etc.)

Internal Medical Policy Committee 1-19-2021 Annual Review

Internal Medical Policy Committee 1-20-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 1-26-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 3-19-2024 Archiving- Effective May 06, 2024

Archived policy

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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