CT (Virtual) colonoscopy

Section: Radiology
Effective Date: July 01, 2018
Revised Date: November 15, 2019
Last Reviewed: November 14, 2019

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 patients, CT colonography may be used in asymptomatic patients 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

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