CurrentBlue Cross Blue Shield - IllinoisPolicy CPCPLAB071

Colorectal Cancer Screening - Laboratory Tests

Defines Blue Cross Blue Shield of Illinois reimbursement stance for laboratory-based colorectal cancer screening tests and which tests are reimbursable or excluded for covered members.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyColorectal Cancer Screening - Laboratory Tests

Policy CodePolicy CPCPLAB071

Change TypeNo material change

Effective DateSep 5, 2025

Next Review Date

Key ActionSubmit accurate documentation and be prepared to provide additional documentation upon request for claims review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

45-75ages 45-75

3 yrsFIT-DNA interval

Not reimb.ColoVantage

Not reimb.Over 75

ListedExcluded techniques

Coverage Criteria for Colorectal Cancer Screening Tests

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Primary coverage criteria

Reimbursement positions for specified colorectal cancer screening tests and populations.

ALL of the following

ALL of the following
- Age range: 45-75
- Symptom status: asymptomatic
- Tests: FIT (preferred) or gFOBT
ALL of the following
- Test: FIT-DNA (Cologuard or Cologuard Plus)
- Interval: once every 3 years

ALL of the following

Use of methylated Septin 9 (ColoVantage) for colorectal cancer screening is not reimbursable.
Average-risk, asymptomatic individuals over 75 years of age — colorectal cancer screening is not reimbursable.
Any of the following excluded screening techniques
- Screening for anal cytologic abnormalities (anal pap smear)
- Screening for anal HPV infection
- Screening using cell-free DNA techniques (e.g., Guardant Shield)

Documentation and Claim Review Requirements

Documentation Required

Documentation and claim review — submit accurate documentation and provide additional records upon request

Providers are responsible for submitting accurate documentation and coding using HIPAA‑approved code sets and industry-standard coding guidelines. Claims are subject to code edit protocols and plan review; upon request, providers must submit additional documentation to support the claim.

Submit claims using valid HIPAA-approved code combinations and industry coding guidelines (e.g., CPT, HCPCS, ICD-10).
Claims are reviewed against benefit coverage, provider contract terms, medical policies, coding policies, and coding software logic.
Provide additional documentation upon request to support services billed.

Definitions and Lab Reimbursement Criteria

Plan lab reimbursement criteria

DefinitionPlan lab reimbursement criteria

Scope noteNot all requirements apply to each product; providers should review specific plan documents for coverage eligibility.

Provider obligationProviders are urged to review Plan documents for eligible coverage for services rendered.

Screening test types referenced

Reimbursable stool-based testsFecal immunochemical test (FIT) or guaiac fecal occult blood test (gFOBT) — annual screening for asymptomatic individuals ages 45–75.

Reimbursable multitarget stool DNAFIT‑DNA (Cologuard™ or Cologuard Plus™) — may be reimbursable once every 3 years.

Not reimbursable — methylated Septin 9ColoVantage — use for colorectal cancer screening is not reimbursable.

Not reimbursable — anal screening testsAnal cytologic screening (anal pap) and anal HPV testing are not reimbursable.

Not reimbursable — cfDNA techniquesCell‑free DNA techniques (e.g., Guardant Shield™) are not reimbursable for colorectal cancer screening.