Screening Colonoscopy for Colorectal Cancer in Individuals at Average Risk
DESCRIPTION
According to the American Cancer Society there will be an estimated 148,810 new cases of colorectal cancer in the year 2008. Colon cancer comprises 72% of cases while 28% are rectal cancer. Colorectal cancer is the third most common cancer in men and women. An estimated 49,960 deaths from colorectal cancer are expected to occur in 2008.
A primary risk factor for colorectal cancer is age, with more than 90% of cases diagnosed in individuals over the age of 50 years. The 5-year survival rate for early stage cancers is over 90%, while the 5-year survival for those diagnosed with wide spread cancer is less than 10%.
Signs and symptoms of colorectal cancer may include rectal bleeding, blood in the stool, and a change in bowel habits. A personal or family history of colorectal cancer or polyps and a personal history of inflammatory bowel disease have been associated with increased risk for colorectal cancer. Other possible risk factors include physical inactivity, high-fat and/or low-fiber diet, as well as inadequate intake of fruits and vegetables.
According to the American Society for Gastrointestinal Endoscopy, "indirect evidence suggests that most cancers develop from adenomatous polyps and that it takes an average of 10 years for a < 1cm polyp to transform into invasive colorectal cancer. Given the finding that colon polyps and early cancers are usually asymptomatic and the above mentioned dwell time between polyp and cancer, there appears to be a significant opportunity for colorectal prevention by screening asymptomatic individuals."
The American Medical Association (AMA) and collaborating organizations issued a Quality Care Alert in July of 2001 that addresses colonoscopy screening for colorectal cancer. This Quality Care Alert supports the use of colonoscopy as a colorectal cancer screening every 10 years for individuals age 50 years and older who have no other risk factor but age. The Quality Care Alert also addresses annual fecal occult blood test (FOBT), flexible sigmoidoscopy, and double-contrast barium enema as colorectal cancer screening options.
During a colonoscopy, a colonoscope is inserted in the anus and moved through the colon past the splenic flexure in order to visualize the lumen of the rectum and colon. The procedure is performed in the outpatient setting with sedation.
POLICY
A colonoscopy done every ten years for the screening of colorectal cancer is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
MEDICAL APPROPRIATENESS
A colonoscopy done every ten years for the screening of colorectal cancer is considered medically appropriate if ALL of the following criteria are met:
The individual is asymptomatic
The individual is 50 years or older with no other risk factor but age
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
SOURCES
Agency for Healthcare Research and Quality. (2008, October). The U.S. Preventive Services Task Force recommendation on screening for colorectal cancer. Retrieved October 16, 2008 from http://www.ahrq.gov/clinic/uspstf/uspscolo.htm.
American Cancer Society. (2006, March). Detailed guide: Colon and rectal cancer. Can colorectal polyps and cancer be found early? Retrieved July 20, 1006 from http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_colon_and_rectum_cancer_be_found_early.asp.
American Cancer Society. (2008). Cancer Facts and Figures 2008 - 2010. Retrieved January 22, 2009, from http://www.cancer.org/acs/groups/content/@nho/documents/document/f861708finalforwebpdf.pdf.
American Medical Association. (2005). Physician consortium for performance improvement clinical performance measures - colorectal cancer screening. Retrieved July 20, 2006 from http://www.ama-assn.org/ama1/pub/upload/mm/370/preventiveset-12-05.pdf.
Complete Guide To Medicare Coverage Issues [Computer software]. (2010, April). Colorectal cancer screening (NCD 210.3, p 2-162 – 2-163). Ingenix.
Davila, R.E., Rjan, E., Baron, T.H., Egan, J.V., Faigel, D.O., Gan, S.I., et al. (2006). ASGE guideline: Colorectal cancer screening and surveillance. Gastrointestinal Endoscopy, 63 (4), 546-557.
Levin, B., Lieberman, D.A., McFarland, B, Smith, R.A., Brooks, D., Andrews, K.S., et al. (2008). Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: A joint guideline from the American Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA- A Cancer Journal for Clinicians, 58 (3), 130-160.
ORIGINAL EFFECTIVE DATE: 1/1/2002
MOST RECENT REVIEW DATE: 11/11/2010
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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