CT (Virtual) Colonoscopy - DIAGNOSTIC - CAM 723

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. Polyps may be adenomatous (which have the potential to become malignant) or completely benign.

Colorectal cancer (CRC) is the third most common cancer and the second most common cause of cancer death in the United States. Symptoms include blood in the stool, change in bowel habit, abdominal pain, and unexplained weight loss. 

Relative contraindications to CTC include: symptomatic acute colitis, acute diarrhea, recent acute diverticulitis, recent colorectal surgery, symptomatic colon-containing abdominal wall hernia, small bowel obstruction. It is not indicated in routine follow-up of inflammatory bowel disease, hereditary polyposis or non polyposis cancer syndromes, evaluation of anal disease, or the pregnant or potentially pregnant patient. For all high-risk individuals, colonoscopy is preferred.

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. Conventional colonoscopy is the main method currently used for examining the colon.

OVERVIEW:
Request for a follow-up study -- A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Policy  
INDICATIONS FOR CT COLONOGRAPHY (VIRTUAL COLONOSCOPY):

For diagnostic (symptomatic patient) evaluation when conventional colonoscopy is contraindicated or could not be completed: (ACR, 2018; NCCN, 2019; Rex, 2017)

  • Patient had failed or incomplete colonoscopy. 
  • Patient has an obstructive colorectal cancer.
  • When colonoscopy is medically contraindicated or not possible (e.g., patient is unable to undergo sedation or has medical conditions such as a recent myocardial infarction, recent colonic surgery, a bleeding disorder, or severe lung and/or heart disease).
  • For a 3 year follow-up when at least one polyp of 6 mm in diameter detected at CTC if patient does not undergo polypectomy (or is unwilling or unable to undergo colonoscopy).  

References 

  1. Kahi CJ, Boland CR, Dominitz JA, et al. Colonoscopy surveillance after colorectal cancer resection: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. 2016; 111:337-46. Epub 2016 Feb 12. https://gi.org/guideline/colonoscopy-surveillance-after-colorectal-cancer-resection-recommendations-of-the-us-multi-society-task-force-on-colorectal-cancer/.
  2. National Comprehensive Cancer Network (NCCN). NCCN Guidelines Version 2.2019 - Colorectal Cancer Screening. 2019. 
  3. Rex DK, Boland CR, Dominitz JA, et al. Colorectal cancer screening: Recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. 2017 Jul; 112(7):1016-30. Epub 2017 Jun 6. https://gi.org/guideline/colorectal-cancer-screening-recommendations-for-physicians-and-patients-from-the-u-s-multi-society-task-force-on-colorectal-cancer/.
  4. Smith RA, Cokkinides V, Brooks D. Cancer screening in the United States, 2011: A review of current American Cancer Society guidelines and issues in cancer screening. CA Cancer J Clin. 2011; 6(1):8-30. doi: 10.3322/caac.20096.
  5. Spada C, Stoker J, et al. Clinical Indications for computed tomographic colonography: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastrointestinal and Abdominal Radiology (ESGAR) Guideline. Eur Radiol. 2015; 25:331-345.
  6. U.S. Preventative Services Task Force (USPTF).Screening for Colorectal Cancer US Preventitive Task Force Recommendation Statement. JAMA. 2016 June 21; 315(23).  
  7. Van Der Meulen MP, Lansdorp-Vogelaar I, Goede SL, et al. Colorectal cancer: Cost-effectiveness of colonoscopy versus CT colonography screening with participation rates and costs. Radiology. 2018 Jun; 287(3):901-11. Epub 2018 Feb 27.
  8. Whitlock EP, Lin JS, Liles E, et al. Screening for colorectal cancer: A targeted, updated systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008; 149(9):638-58. doi: 10.7326/0003-4819-149-9-200811040-00245.  
  9. Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer Screening for average risk-adults: 2018 guideline update from the American Cancer Society. Ca Cancer J Clin. 2018 Jul; 68(4):250- 81.

Coding Section

Code Number Description
CPT 74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material
  74262 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2020 Forward     

11/10/2021 

Annual review, no change to policy intent. 

11/12/2020

New Policy

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