CurrentBlue Cross Blue Shield - IllinoisPolicy CPCPLAB071

Colorectal Cancer Screening — Laboratory Tests

Coverage and lab reimbursement criteria for colorectal cancer screening tests (stool- and blood-based), governing providers submitting claims to Blue Cross and Blue Shield of Illinois products. Affects lab providers and ordering clinicians for BCBSIL members.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyColorectal Cancer Screening — Laboratory Tests

Policy CodePolicy CPCPLAB071

Change TypeNew policy

Effective DateSep 5, 2025

Next Review Date

Key ActionOrder and document FIT annually for asymptomatic individuals aged 45–75 (FIT preferred); use FIT‑DNA every 3 years if applicable and avoid non‑reimbursable tests such as methylated Septin 9.

SourceLink

POLICY UPDATE CHANGES

New policy implemented effective 01/01/2026 establishing coverage and non-coverage rules for colorectal cancer screening laboratory tests.

45-75Age range (reimbursable)

annualFIT frequency

3 yrsFIT‑DNA frequency

over 75Not reimbursable (age)

Septin 9Specifically not reimbursable

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Coverage Criteria for Colorectal Cancer Screening Tests

Reimbursable screening tests

Covered when ALL of the following are met:

FIT or gFOBT coverage: Asymptomatic individuals 45 to 75 years of age; annual screening with a fecal immunochemical test (FIT) (preferred) or guaiac fecal occult blood test (gFOBT) may be reimbursable.age 45-75; frequency annual

FIT preferred over gFOBT

FIT-DNA coverage: FIT-DNA (Cologuard or Cologuard Plus) may be reimbursable once every 3 years for screening.every 3 years

Examples provided: Cologuard, Cologuard Plus

Not reimbursable methods: Methylated Septin 9 (ColoVantage), screening for anal cytologic abnormalities (anal pap smear), anal HPV infection, and screening using cell-free DNA techniques (e.g., Guardant Shield) are not reimbursable.

Age exclusion: For average-risk, asymptomatic individuals over 75 years of age, colorectal cancer screening is not reimbursable.

The following colorectal cancer screening tests are not reimbursable: screening for anal cytologic abnormalities (anal Pap smear), screening for anal HPV infection, and the blood-based methylated Septin 9 assay (ColoVantage). In addition, screening using cell-free DNA techniques (for example, Guardant Shield™) is not reimbursable.

For average-risk, asymptomatic individuals over 75 years of age, colorectal cancer screening is not reimbursable.

Who Is Covered

Average-risk, asymptomatic individuals aged 45–75 for colorectal cancer screening

Covered when ALL of the following are met:

Population: Average-risk, asymptomatic individuals aged 45 to 75 years.

Preferred stool-based test and frequency: Fecal immunochemical test (FIT) is the preferred stool-based screening test and may be reimbursed when performed annually.annual

FIT preferred

Alternate stool-based test and frequency: FIT-DNA (multitarget stool DNA; examples: Cologuard or Cologuard Plus) may be reimbursable when performed once every 3 years.every 3 years

Screening Frequency Limits

FIT or gFOBT — Annual frequency limit

Frequency limitAnnual (once per year)

Applies toFecal immunochemical test (FIT) or guaiac fecal occult blood test (gFOBT)

Eligible populationAsymptomatic individuals 45–75 years of age

FIT-DNA (Cologuard or Cologuard Plus) — Frequency

Frequency limitOnce every 3 years

Test examplesFIT-DNA (Cologuard™ or Cologuard Plus™)

ContextMay be reimbursable for colorectal cancer screening

Procedure Codes and Age-Based Eligibility

Procedure Codesmixed

No codes listed

Age-based screening eligibility

Reimbursable age range45–75 years (average-risk, asymptomatic individuals)

Not reimbursableAverage-risk, asymptomatic individuals over 75 years of age

Screening contextApplies to colorectal cancer screening tests (stool-based and FIT-DNA per policy rules)

Provider Actions, Documentation, and Denials

Prior Authorization

Prior authorization — Follow product-specific requirements in member plan documents. If prior authorization is required by the member's benefit plan or provider contract, obtain approval per the applicable product rules before rendering services.

Check the member's specific plan documents for any prior authorization requirements.
Prior authorization applicability varies by product; none are specified generically in this policy.

Documentation Required

Documentation and Coding Expectations

Providers must submit accurate, complete documentation and bill using valid HIPAA-adopted code sets. Claims may be reviewed against coding edits, benefit terms, provider contract language, clinical payment and coding policies, and coding software logic; additional documentation may be requested.

Use industry-standard code sets and guidance (CPT, HCPCS, ICD-10-CM/PCS, NDCs, DRG rules, CMS NCCI edits, etc.).

Ordering and Reimbursement Requirements

Billing Rule

Ordering requirements — verify plan rules and submit accurate coding

Follow applicable plan documents for product‑specific ordering and reimbursement requirements; ensure submitted claims include accurate coding and supporting documentation.

Verify member coverage and any product-specific lab management criteria prior to ordering.
Ensure claims are coded per industry standards and include required documentation for reimbursement.

Definitions of Tests

FIT — Definition and preferred use

DefinitionFecal immunochemical test (FIT)

Preferred usePreferred stool-based annual screening test for asymptomatic individuals ages 45–75

Alternative testGuaiac fecal occult blood test (gFOBT) may be reimbursable annually

FIT-DNA — Definition and interval

DefinitionFIT-DNA (multitarget stool DNA test)

ExamplesCologuard™ or Cologuard Plus™

Screening intervalPerformed once every 3 years for colorectal cancer screening

Tests and Uses Not Covered

NOT COVERED: Methylated Septin 9 (ColoVantage); anal cytology (anal Pap smear); anal HPV screening; and screening using cell-free DNA techniques (for example, Guardant Shield™).

Background

BACKGROUND: Colorectal cancer screening reduces mortality and may be performed using multiple modalities. Stool-based tests (including annual fecal immunochemical test/FIT or guaiac FOBT, and FIT-DNA such as Cologuard™ every 3 years) and colonoscopy are among the accepted screening approaches; this policy specifies preferred and reimbursable laboratory-based screening methods and identifies tests that are not reimbursable.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyColorectal Cancer Screening — Laboratory Tests

Policy CodePolicy CPCPLAB071

Change TypeNew policy

Effective DateSep 5, 2025

Next Review Date

SourceLink

On This Page

Not reimbursable tests: Blood-based methylated Septin 9 (ColoVantage) and cell-free DNA techniques (e.g., Guardant Shield) are not reimbursable for colorectal cancer screening.

Age-related exclusion: Screening is not reimbursable for average-risk, asymptomatic individuals older than 75 years of age.

Submit supporting clinical documentation upon request to substantiate medical necessity and code selection.

Denial Risk

Triggers for Denial

Denial triggers — Claims for colorectal cancer screening may be denied when submitted for non-covered indications or populations. Review coverage criteria carefully before billing.

Screening in average-risk, asymptomatic individuals >75 years of age is not reimbursable and may be denied.
Tests explicitly listed as not reimbursable (e.g., methylated Septin 9/ColoVantage, anal cytology for screening, anal HPV screening, cell-free DNA techniques like Guardant Shield™) are subject to denial.
Coverage for specific tests (e.g., FIT, gFOBT, FIT-DNA/Cologuard™) depends on age and frequency rules in the member's product.
Benefits and applicability vary by product; if the submitted service is not included in the member's plan documents, the claim may be denied.

Note

Plan / Product Variability

Provider-impact highlight — The Plan has implemented lab management reimbursement criteria that vary by product. Providers should confirm eligibility and coverage details in the member's plan documents prior to performing or billing services.

Not all reimbursement requirements apply to every product; verify the member's specific benefit booklet or certificate.
Frequency and eligible age ranges (for example, FIT annually for ages 45–75; FIT‑DNA every 3 years) should be confirmed against the member's plan.
When in doubt, obtain prior authorization or pre-service confirmation per the product rules.

methylated Septin 9 (ColoVantage) — Coverage status

Test nameMethylated Septin 9 (ColoVantage)

ModalityBlood-based methylation assay

Coverage stanceNot reimbursable for colorectal cancer screening