ModifiedArkansas Blue Cross and Blue ShieldPolicy 2003018

Genetic Test: Fecal and Serologic Genetic Testing to Detect Colorectal Cancer, Screening

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This policy governs coverage of stool-based genetic and molecular testing used to screen for colorectal cancer. Cologuard Plus is covered for average-risk individuals who have not undergone another colorectal cancer screening method within the prior year, while other specified stool-based molecular tests and indications are not covered.

Policy Summary

PayerArkansas Blue Cross and Blue Shield

PolicyGenetic Test: Fecal and Serologic Genetic Testing to Detect Colorectal Cancer, Screening

Policy CodePolicy 2003018

Change TypeModified

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionDocument that the individual is at average risk for colorectal cancer and has not undergone another colorectal cancer screening method within the preceding year.

SourceLink

POLICY UPDATE CHANGES

Restricted coverage was added for Cologuard Plus (0464U) as a colorectal cancer screening test for average-risk individuals who have not been screened by another method within the last year.

1Covered named test

Average riskRequired risk category

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ModifiedArkansas Blue Cross and Blue ShieldPolicy 2003018

Genetic Test: Fecal and Serologic Genetic Testing to Detect Colorectal Cancer, Screening

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Sign up for arkansas_blue_cross_blue_shield Policy 2003018 alerts

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Policy Summary

PayerArkansas Blue Cross and Blue Shield

PolicyGenetic Test: Fecal and Serologic Genetic Testing to Detect Colorectal Cancer, Screening

Policy CodePolicy 2003018

Change TypeModified

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionDocument that the individual is at average risk for colorectal cancer and has not undergone another colorectal cancer screening method within the preceding year.

SourceLink

POLICY UPDATE CHANGES

Restricted coverage was added for Cologuard Plus (0464U) as a colorectal cancer screening test for average-risk individuals who have not been screened by another method within the last year.

1Covered named test

Average riskRequired risk category

Coverage Criteria

Cologuard Plus covered screening

Covered when all of the following are met:

Cologuard Plus screening eligibility

Covered test: The test is Cologuard Plus (0464U).
Average-risk screening population: The individual is at average risk of colorectal cancer.
No recent screening: The individual has not been screened by another colorectal cancer screening method within the last year.No other colorectal cancer screening method within 12 months
Coverage basis: The applicable member benefit certificate Primary Coverage Criteria are met regarding scientific evidence of effectiveness in improving health outcomes; for contracts without Primary Coverage Criteria, the service is considered medically necessary and covered.

Other stool-based molecular testing not covered

Not covered when any of the following apply:

Noncovered stool-based genetic or molecular testing

Unaddressed stool DNA indication: DNA analysis of stool samples is used for an indication not addressed by this policy or another policy.
Stool RNA analysis: RNA analysis of stool samples is performed, including Colosense (0421U).
Combined stool DNA/RNA testing: Combination testing of DNA with RNA analysis of stool samples is performed.
Other stool-based protein marker or molecular testing: Other stool-based protein marker or molecular genetic testing is used to detect or screen for colorectal cancer.

Cologuard Plus (0464U) and any other DNA analysis of stool samples are excluded from coverage when used for an indication not addressed by this policy or another applicable policy.

RNA analysis of stool samples, including Colosense (0421U), is excluded from coverage. Combination testing that analyzes both stool DNA and RNA is also excluded.

For contracts with applicable Primary Coverage Criteria, coverage requires scientific evidence of effectiveness in improving health outcomes. For contracts without Primary Coverage Criteria, Cologuard Plus or other stool-based DNA, RNA, protein-marker, or molecular genetic testing outside the covered indication is considered not medically necessary or investigational and is not covered. These services are specific contract exclusions in most member benefit certificates of coverage.

Covered Indications

Colorectal cancer screening for average-risk individuals

Covered for colorectal cancer screening when all of the following are met:

Covered screening indication

Average-risk individual: The individual is at average risk of colorectal cancer.
No screening within the prior year: The individual has not been screened by another colorectal cancer screening method within the last year.No other colorectal cancer screening method within 12 months
Covered test: The covered test is Cologuard Plus (0464U), subject to applicable member benefit criteria.

Eligibility Requirements

The individual must not have undergone another colorectal cancer screening method within the last year (the preceding 12 months).

Not Covered Services

The following are not covered: stool DNA analysis for indications not addressed by this policy or another policy; stool RNA analysis, including Colosense (0421U); combined stool DNA/RNA testing; and other stool-based protein-marker or molecular genetic testing used to detect or screen for colorectal cancer.

Coding and Coverage Status

Covered genetic testingCPTCovered

0464U

Cologuard Plus

Not covered stool-based molecular testingCPTNot Covered

0421U

Colosense RNA analysis of stool samples

Interval Since Another Colorectal Cancer Screening Method

Required intervalNo other colorectal cancer screening method within the last year

Equivalent timeframe12 months since another colorectal cancer screening method

Applies toCologuard Plus (0464U) colorectal cancer screening

Provider Documentation and Denial Risks

Documentation Required

Document screening eligibility

Document that the individual is at average risk for colorectal cancer and has not undergone another colorectal cancer screening method within the preceding year.

Covered test: Cologuard Plus (0464U).
Document no other colorectal cancer screening method within the last year.

Denial Risk

Failure to meet screening eligibility

Cologuard Plus (0464U) is not covered when the individual is not at average risk for colorectal cancer or has been screened by another colorectal cancer screening method within the last year.

Confirm average-risk status.
Confirm no other colorectal cancer screening method within the last year.

Policy Background

This policy addresses stool-based genetic and molecular testing used to detect or screen for colorectal cancer. Coverage is limited to Cologuard Plus for individuals at average risk who have not undergone another colorectal cancer screening method within the prior year; other specified stool-based molecular approaches are considered not medically necessary or investigational and are not covered.