Virtual Colonoscopy (Computed Tomography Colonography)
Virtual colonoscopy (i.e., CT colonography) is an imaging modality of the colon that has been investigated as an alternative to conventional endoscopic colonoscopy. It has been most widely studied as an alternative screening technique for colon cancer and for the diagnosis of colorectal cancer in individuals with related symptoms. This procedure uses thin-section helical computed tomography 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 offline. If polyps or cancer are identified, the individual should be referred for conventional colonoscopy for polyp removal and/or biopsy.
While computed tomography colonography requires a full bowel preparation similar to conventional colonoscopy, no sedation is required and the examination is less time-consuming. The technique involves gas insufflation of the intestine which may be uncomfortable for the individual.
Virtual colonoscopy (i.e., computed tomography colonography) for the diagnosis of colorectal cancer is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Virtual colonoscopy (i.e., computed tomography colonography) for screening for colorectal cancer every five years is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Virtual colonoscopy (i.e., computed tomography colonography) is considered medically appropriate if ANY ONE of the following criteria are met:
When used for the diagnosis of colorectal cancer with ANY ONE of the following:
Individuals who have failed conventional colonoscopy (e.g. due to a known colonic lesion, structural abnormality or technical difficulty)
Individuals who meet the criteria for conventional colonoscopy but conventional colonoscopy is medically contraindicated (e.g., intolerance to sedation, coagulopathy, myocardial infarction within last 60 days)
When used for the screening of colorectal cancer with ALL of the following:
Frequency not to exceed once every 5 years
Ages 50 - 75 years
No history of adenoma
No history of inflammatory bowel disease
No first degree family history of colorectal cancer
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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.
American College of Radiology. (2013). ACR Appropriateness Criteria® colorectal cancer screening. Retrieved February 17, 2016 from the National Guideline Clearinghouse (NGC: 47650).
Qaseem, A., Denberg, T., Hopkins, R., Humphrey, L., et al. Screening for colorectal cancer: a guidance statement from the American College of Physicians. Annals of Internal Medicine, 156, 378-386.
U.S. Preventive Services Task Force. (2013) Screening for colorectal cancer: U.S. preventive services task force recommendation statement. Retrieved January 5, 2017 from the National Guideline Clearinghouse (NCG#011005).
ORIGINAL EFFECTIVE DATE: 8/1/2001
MOST RECENT REVIEW DATE: 12/20/2017
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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