Modifiedblue cross blue shield - kansasPolicy N/A

Virtual Colonoscopy / CT Colonography

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Defines coverage and clinical criteria for CT colonography (virtual colonoscopy) as a colorectal cancer screening alternative for Blue Cross and Blue Shield of Kansas members, and summarizes evidence and intended use.

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Modifiedblue cross blue shield - kansasPolicy N/A

Virtual Colonoscopy / CT Colonography

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Policy Summary

PayerBlue Cross Blue Shield - Kansas

PolicyVirtual Colonoscopy / CT Colonography

Policy CodePolicy N/A

Change TypeScreening age range updated (50→45)

Effective DateNov 20, 2024

Last ReviewNov 20, 2024

Next Review DateN/A

Key ActionDocument patient is average-risk, asymptomatic and aged 45–75 and that no other CRC screening was performed within the recommended interval (or document failed colonoscopy) to support coverage.

SourceLink

POLICY UPDATE CHANGES

Section A changed coverage age range from '50 and 75 years' to '45 and 75 years'.

Policy language was revised previously to allow CT colonography as medically necessary in average-risk, asymptomatic individuals between specified ages when no other CRC screening has been performed during the recommended interval.

Previous language limiting CT colonography to patients who failed colonoscopy or were not appropriate candidates was removed and later restructured in subsequent revisions.

45-75Screening age range (policy updated)

74261-74263Primary CPT codes

91%Pooled sensitivity ≥10 mm

1–7 mSvRadiation dose (typical)

27–69%Extracolonic findings

Coverage Criteria

inv-01: Medically necessary screening indications

Covered when ALL of the following are met:

Primary coverage criteria: 1) Individual is average-risk for colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, inflammatory bowel disease, or relevant hereditary colorectal cancer syndromes and no family history of colorectal cancers or adenomatous polyps); 2) Individual is asymptomatic for colorectal disease (no lower GI pain, no blood in stool, no positive FOBT/FIT); 3) Individual is between 45 and 75 years of age; 4) No other colorectal cancer screening has been performed during the recommended screening interval OR individual failed to successfully complete a conventional colonoscopy (an inadequate prep does not constitute a failed colonoscopy); 5) Prior screening intervals considered: guaiac FOBT within 1 year OR FIT within 1 year OR multi-target stool DNA within 3 years OR colonoscopy within 10 years OR prior CT colonography within 5 years OR flexible sigmoidoscopy within 5 years.

Policy A and Policy Guidelines; age range updated per revision.

inv-02: Experimental / investigational

Not covered indications: Except for the indications outlined in the policy statements above, virtual colonoscopy / CT colonography is considered experimental / investigational.

Policy B.

inv-03: Evidence-based coverage considerations

Evidence-based considerations and situations where CTC is used:

Screening vs Colonoscopy: CTC diagnostic accuracy varies across studies but generally approaches colonoscopy performance for lesions ≥10 mm; increased participation with CTC (particularly with reduced/no cathartic prep) may offset some advantages of colonoscopy in population screening.lesion size ≥10 mm

Section summary, meta-analyses, and RCTs (chunks 28,27,19).

Use after positive screening or symptoms: CTC can be used to evaluate individuals with a positive CRC screening test or signs/symptoms of CRC, but findings on CTC require confirmation with optical colonoscopy; in higher-prevalence populations, colonoscopy is usually preferred because of need for immediate intervention and higher pretest probability.N/A

Clinical context and recommendation; pooled sensitivity for ≥6 mm in FOBT-positive patients ~88.8% (chunk 36).

Harms and tradeoffs:

inv-04: Covered with criteria

Covered when ALL of the following are met for diagnostic/screening use:

Preferred strategy: Colonoscopy is usually the preferred clinical strategy for patients with positive screening tests or symptoms of colorectal cancer due to higher disease prevalence.

Section Summary: Colon Cancer Diagnosis (chunk 44).

When CTC is reasonable: CTC may be a reasonable option when patients are unable to undergo colonoscopy (examples: unsafe bowel preparation, frailty, immobility, contraindication to colonoscopy) or when colonoscopy is incomplete.

Section supports CTC as reasonable alternative when colonoscopy not feasible (chunk 44).

Test performance considerations: CTC has high sensitivity for polyps ≥10 mm and reasonably high sensitivity for adenomas ≥6 mm but variable specificity; positive CTC findings require follow-up colonoscopy and CTC may lead to more additional colonic evaluations compared with colonoscopy in symptomatic populations.

Summary of diagnostic accuracy and RCT findings (chunk 44).

inv-05: Screening coverage/age criteria

Covered when ALL of the following are met (policy history and updates):

screen_age: Patient age is within the screening range (policy language updated from 50–75 years to 45–75 years).45-75 years

Revision history documents change (chunk 66).

previous_screening_interval: (Historical policy language) CT colonography considered medically necessary in average-risk, asymptomatic individuals when no other colorectal cancer screening has been performed during the recommended screening interval (examples: guaiac FOBT within 1 year, FIT within 1 year, multi-target stool DNA within 3 years, colonoscopy within 10 years, prior CTC within 5 years, flexible sigmoidoscopy within 5 years).see policy

Referenced in coding/revision history (chunk 62) and original policy A (chunk 7).

inv-06: Diagnostic / Special clinical situations

CT colonography may be considered medically necessary in specific clinical situations historically captured in the policy:

failed_colonoscopy: Patient failed to successfully complete a conventional colonoscopy (an inadequate bowel preparation does not constitute a failed colonoscopy).N/A

Described in policy and revision history (chunks 7,62).

not_candidate_for_colonoscopy: Patient is not an appropriate candidate to safely undergo conventional colonoscopy (examples include known colonic obstruction or stenosing lesions, inability to discontinue anticoagulant therapy, or high anesthesia risk).N/A

Examples listed in coding revisions (chunk 63).

inv-07: Not medically necessary / investigational

general_exclusion: Except for the indications outlined in the policy statements, virtual colonoscopy / CT colonography is considered experimental / investigational.N/A

Historic not medically necessary language retained in revisions (chunk 62).

Except for the specific indications enumerated in this policy (screening in average‑risk, asymptomatic individuals aged 45–75 years meeting the interval criteria, or when a conventional colonoscopy has failed or is not feasible), CT colonography (CTC) / virtual colonoscopy is considered experimental/investigational and is not covered. This stance applies to uses outside the defined screening age, risk status, screening‑interval conditions, or the limited diagnostic circumstances described in the policy.

CTC findings that would ordinarily require confirmatory optical colonoscopy should not be relied on as the sole diagnostic test when the likelihood of needing invasive confirmation is high. The policy emphasizes that positive or concerning CTC findings require follow‑up colonoscopy, and using CTC alone in situations where confirmatory colonoscopy is likely may be inappropriate and could affect coverage.

Use of CTC as the first‑line diagnostic evaluation in symptomatic patients is discouraged when conventional colonoscopy is feasible. An RCT comparing CTC with colonoscopy in symptomatic adults showed a significantly greater need for additional colonic investigations after CTC (30.0% vs 8.2%; p<.001), supporting the recommendation that colonoscopy remain the preferred initial test when it can be performed.

Historically, prior policy language explicitly stated that, except for the listed indications, virtual colonoscopy / CT colonography was considered experimental/investigational. This historical coding and revision history documents that CTC use outside specified circumstances was previously and explicitly excluded.

Any use of CT colonography that does not meet the policy's specified criteria for patient risk status, symptom status, age range, screening interval, or the limited diagnostic exceptions (e.g., failed colonoscopy or contraindication to colonoscopy) is considered not medically necessary (NMN) and will be treated as experimental/investigational under this policy.

No randomized controlled trials were identified that directly compare patient health outcomes for screening with CTC versus no CTC; therefore, direct evidence of CTC's effect on health outcomes is lacking. Because direct RCT evidence is absent, assessment of clinical utility relies on indirect evidence and test performance.

The clinical validity of CTC for colorectal cancer diagnosis has not been fully established in some patient populations. When test performance is uncertain, a complete chain of evidence demonstrating clinical utility cannot be constructed, and this limits conclusions about net health‑outcome benefits in those groups.

Earlier policy versions explicitly labeled virtual colonoscopy / CT colonography as not medically necessary except for the limited situations described (for example, when conventional colonoscopy could not be safely performed or had failed). Subsequent revisions restructured coverage statements but retained the core distinction between covered indications and investigational uses.

Covered Indications

inv-42: Screening for colorectal cancer in average-risk asymptomatic individuals

screening_average_risk: Average-risk, asymptomatic individuals aged 45–75 years who have not had other recommended CRC screening within specified intervals, or individuals who failed to successfully complete a conventional colonoscopy (inadequate prep does not constitute failure).

Reflects Policy A and Policy Guidelines (chunks 7,8).

inv-43: Evaluation after positive CRC screening test or symptoms

post_positive_or_symptomatic_evaluation: Individuals with a positive CRC screening test (e.g., FOBT/FIT) or signs/symptoms suggestive of colorectal cancer may be evaluated with CTC when colonoscopy is not feasible; findings on CTC require confirmation with optical colonoscopy and colonoscopy is the preferred initial test when feasible.N/A

Clinical context and systematic review data support reasonable sensitivity but requirement for confirmatory colonoscopy (chunks 29,36).

Provider Actions & Authorization

Prior Authorization

Provider action: Use after positive screening / symptomatic; prior authorization and documentation expectations

CT colonography (CTC) is generally NOT the preferred initial diagnostic test for individuals with a positive CRC screening test or signs/symptoms of colorectal cancer because disease probability is higher and findings on CTC require confirmation by colonoscopy. Use CTC only when colonoscopy is not feasible or contraindicated and document clinical justification.

CTC findings that suggest cancer or clinically significant polyps require confirmatory optical colonoscopy.
Optical colonoscopy is the usual comparator and is preferred when disease probability is high (e.g., positive FOBT/FIT, symptomatic patients).
CTC may be reasonable when colonoscopy cannot be performed safely (e.g., patient unable to tolerate bowel prep, frailty, contraindication to anesthesia) or when colonoscopy was attempted but not successfully completed (inadequate prep is not a failed colonoscopy).
Prior authorization may be required per member contract; CPT codes 74261/74262/74263 are subject to medical necessity review and only covered when performed according to policy criteria.
Sequencing: CTC is covered as a screening technique only for average-risk, asymptomatic individuals 45–75 years who have not had other CRC screening within recommended intervals (see policy criteria for acceptable prior tests and timeframes).
Denial risk increases if the preferred diagnostic pathway (direct colonoscopy for symptomatic or positive-screening patients) is not followed without documented clinical justification.

Coding

Covered CPT Codes (procedure codes listed as applicable)CPTCovered

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.
74263	Computed tomographic (CT) colonography, screening, including image postprocessing.

inv-17: Screening interval mention — CT colonography in past 5 years

Screening interval (historical)CT colonography performed within the past 5 years is listed as a prior screening that would preclude repeat screening by CTC under historical policy language.

Prior Authorization

CT colonography coverage conditional on policy criteria and member contract

Coverage for CT colonography applies only when the policy criteria are met; check the member contract for any prior authorization or benefit limitations.

Verify member-specific benefits and authorization requirements with BCBSKS prior to scheduling.

Note

Use CTC when it improves screening participation versus standard colonoscopy

CT may be favored as a screening option when participation is expected to improve (for example with reduced or noncathartic preparation), otherwise standard colonoscopy remains the primary diagnostic strategy.

Document if a reduced/noncathartic prep is being used to support participation-based justification.

Prior Authorization

Prior authorization recommended when CTC used as colonoscopy alternative; document infeasibility

Frequency Limits

inv-48: CT colonography — every 5 years

Recommended interval for CTC screeningEvery 5 years for CT colonography as an accepted screening interval for average-risk individuals.

inv-49: colonoscopy (comparator) — every 10 years (alternative: colonoscopy)

Comparator interval — optical colonoscopyColonoscopy is generally recommended every 10 years for average-risk individuals and serves as the primary comparator to CTC.

inv-50: CT — CT colonography in the past 5 years (historical reference)

Prior CTC as interval-defining testPolicy historically lists prior CT colonography within the past 5 years as meeting the recommended screening-interval criterion, i.e., prior CTC in past 5 years counts toward interval exclusions.

Definitions

inv-35: CT colonography / virtual colonoscopy — description of modality

Modality descriptionComputed tomography colonography (CTC), also called virtual colonoscopy, uses thin-section helical CT to generate high-resolution 2D axial images and reconstructed 3D endoluminal views as a noninvasive alternative to optical colonoscopy.

inv-36: Average risk — definition

Average risk definitionIndividuals with no personal history of adenomatous polyps, colorectal cancer, inflammatory bowel disease, or relevant hereditary colorectal cancer syndromes, and no family history of colorectal cancers or adenomatous polyps.

inv-37: Asymptomatic — definition

Asymptomatic definitionAbsence of signs or symptoms of colorectal disease, including but not limited to lower gastrointestinal pain, blood in stool, or a positive guaiac fecal occult blood test or fecal immunochemical test (FIT).

Contrast & Preparation Rules

Billing Rule

CTC prep: full bowel preparation and gas insufflation; no sedation

CTC requires full bowel preparation and gas insufflation; no sedation is required for the procedure.

Ensure documentation reflects full bowel prep and gas insufflation per protocol.

Billing Rule

Noncathartic/reduced prep options may increase participation — document regimen

Noncathartic or reduced cathartic preparations (including oral contrast tagging) have been used in trials and may increase screening participation compared with full cathartic preparation.

If reduced or noncathartic prep is used, document the regimen and rationale to support scheduling or authorization.

Not Covered / Investigational

CT colonography for indications outside the defined screening criteria or age/risk ranges (that is, uses not meeting the policy's listed screening or limited diagnostic exceptions) is considered experimental/investigational and therefore not covered under this policy.

CTC should not be used as the sole definitive diagnostic test in situations where there is a high probability that colonoscopic confirmation will be required. The policy notes that findings on CTC require confirmation with colonoscopy, and employing CTC alone in such settings may be inappropriate and affect coverage decisions.

Use of CT colonography for indications outside the policy's defined screening age, risk status, or interval criteria is considered experimental/investigational and is not covered. This exclusion encompasses clinical scenarios not explicitly listed as permitted in the coverage criteria.

Historically, CTC performed outside the specified indications was explicitly described in prior revisions as experimental/investigational and therefore not a covered service. That historical language remains part of the policy record and informs the current exclusion approach.

Background & Evidence Summary

Computed tomography colonography (CTC), also called virtual colonoscopy, is a CT‑based imaging alternative to optical colonoscopy that uses thin‑section helical CT to generate 2‑D and reconstructed 3‑D images of the colon for detection of polyps and colorectal cancer. CTC requires full bowel preparation and gas insufflation, does not require sedation, and may be performed with or without intravenous contrast depending on the clinical indication and the procedure code used.

Evidence & Key Metrics

91.2%pooled sensitivity for lesions ≥10 mm (meta-analysis)

34%CTC participation (Stoop RCT)

30%additional colonic evaluations after CTC (RCT)

1-7 mSvreported radiation dose range for CTC

Revision History

2018-12-20policy_revision

Policy language was revised to allow CT colonography as medically necessary screening for average-risk, asymptomatic individuals between ages 50 and 75 years when no other colorectal cancer screening had been performed within recommended intervals; prior language limiting CTC to failed or unsuitable colonoscopy was removed and reorganized into new clinical-situation guidance.

2023-10-24policy_revision

Screening age range updated from '50 and 75 years' to '45 and 75 years' and ICD-10 codes were removed from the Coding section.

2024-11-20editorial_update

Policy Summary

PayerBlue Cross Blue Shield - Kansas

PolicyVirtual Colonoscopy / CT Colonography

Policy CodePolicy N/A

Change TypeScreening age range updated (50→45)

Effective DateNov 20, 2024

Last ReviewNov 20, 2024

Next Review DateN/A

SourceLink

On This Page

CTC has lower risk of serious adverse events related to sedation/perforation compared with optical colonoscopy but involves ionizing radiation (estimated 1–7 mSv) and frequently detects extracolonic findings that may trigger additional diagnostic evaluation.

Chain of evidence and harms discussed in sections summarizing tradeoffs (chunks 26,28).

Diagnostic accuracy by lesion size: Pooled sensitivity for CTC in screening meta-analysis: overall ~66.8% per-patient, with sensitivity for lesions ≥10 mm approaching ~91.2% and specificity ~87.3%; in FOBT-positive or high-risk symptomatic populations sensitivity for lesions ≥6 mm is ~87%–88.8% with variable specificity.6 mm, 10 mm

Systematic reviews and meta-analyses (chunks 19,36,37).

inv-44: Primary CRC screening in average-risk individuals

primary_screening_use: CTC may be used for primary colorectal cancer screening in average-risk individuals; diagnostic accuracy is variable but generally comparable to colonoscopy for lesions ≥10 mm and reduced/no cathartic preparation protocols may increase participation.lesion size ≥10 mm

Meta-analyses and RCTs describe performance and participation effects (chunks 19,22,28).

inv-45: CRC screening in average-risk individuals

screening_interval_option: CTC every 5 years is an accepted screening interval for average-risk individuals per guideline statements; alternative recommended screening intervals include colonoscopy every 10 years and stool-based tests at guideline-specified intervals.every 5 years

Guideline tables and society recommendations (chunks 49,51,52).

inv-46: Evaluation after positive stool test or symptomatic patients when colonoscopy not feasible

when_colonoscopy_not_feasible: CTC may be used to evaluate patients with a positive fecal screening test or symptoms suggestive of CRC when colonoscopy cannot be performed; sensitivity for lesions ≥6–10 mm is high but specificity varies, and positive findings necessitate colonoscopic confirmation.

Supported by meta-analyses and practice statements (chunks 52,37,36).

inv-47: Screening and select diagnostic situations where colonoscopy is not possible or not completed

screening_average_risk_historical: Average-risk, asymptomatic individuals within recommended screening age range when no other CRC screening has been performed within guideline-recommended intervals (historical policy criteria).see policy

Policy and coding revision history capture historical criteria and examples of prior screening intervals (chunks 62,63).

failed_or_unsuitable_colonoscopy: Patients who failed to complete colonoscopy or are not appropriate candidates for colonoscopy due to known colonic obstruction/stenosing lesions, inability to discontinue anticoagulants, or high anesthesia risk; documentation of clinical justification recommended.N/A

Described in coding revisions and historical policy language (chunks 62,63).

Documentation Required

Provider action: Documentation to support coverage and required coding details

Document the clinical rationale and supporting history when requesting CTC or billing CTC codes. Adequate documentation reduces denial risk and supports medical necessity determinations.

Patient risk status (average risk vs increased risk) and confirmation the patient is asymptomatic for screening indications.
Prior CRC screening history and dates (FOBT within 1 year, FIT within 1 year, mt-sDNA within 3 years, colonoscopy within 10 years, prior CTC within 5 years, flexible sigmoidoscopy within 5 years) to show sequencing compliance.
Clinical justification when CTC is used instead of colonoscopy (e.g., unable to safely complete colonoscopy bowel prep, high anesthesia risk, anticoagulation cannot be stopped, known obstruction/stenosing lesion, frailty, prior incomplete colonoscopy—note inadequate prep alone is not a valid reason).
If CTC is requested after a positive screening test or for symptomatic patients, include explicit rationale for choosing CTC over direct colonoscopy and evidence that colonoscopy is not feasible when applicable.
Include the performed CPT code (74261, 74262, or 74263) and documentation that the procedure met the policy's clinical indications.

Prior Authorization

Provider action: Prior authorization linkage and required supporting documentation

Prior authorization may be required for CT colonography depending on the member's contract; when requested, link authorization to evidence that colonoscopy was not feasible or to policy screening-eligibility criteria.

When prior authorization is requested for CPT 74261/74262/74263, include documentation that colonoscopy was attempted and failed or that colonoscopy is contraindicated/unsafe for this patient.
For screening CTC requests, include evidence the member is average risk and has not had other CRC screening within the specified intervals.
Authorization review will assess medical necessity per the policy; coding will be considered medically necessary ONLY if performed according to the Policy section.

Denial Risk

Provider action: Denial risk from not following preferred diagnostic pathway

Choosing CTC instead of the preferred diagnostic pathway (direct optical colonoscopy) for symptomatic or positive-screening patients without clear clinical justification may result in claim denial or failure of prior authorization.

Direct colonoscopy is usually preferred when disease probability is high; lack of documented contraindication to colonoscopy increases denial risk for CTC.
When CTC is used in lieu of colonoscopy, include clear clinical reasons and supporting notes in the medical record to mitigate denial risk.

Billing Rule

Provider action: Coding / medical necessity linkage and required documentation for billing

Coding for CTC is covered only when the procedure is performed according to policy indications and adequately documented. Use the appropriate CPT code and ensure medical necessity is supported in the record.

Covered CPT codes (when medically necessary per policy): 74261 (CT colonography without contrast), 74262 (with contrast), 74263 (screening CTC).
The code(s) listed are medically necessary ONLY if the procedure is performed according to the Policy section; inclusion in this list does not guarantee member coverage—verify member contract benefits.
When submitting claims or prior authorization requests, attach clinical documentation demonstrating adherence to policy criteria (indication, prior screening history, inability/contraindication to colonoscopy if applicable).

Step Therapy

Provider action: Comparator and sequencing preference (colonoscopy before CTC; historical sequencing)

Sequencing preference: screening CTC is intended as an alternative when other guideline-recommended CRC screening tests have not been completed within recommended intervals or when colonoscopy is not feasible.

Screening CTC coverage applies to average-risk, asymptomatic individuals aged 45–75 years who have not had other CRC screening within recommended intervals (see policy list: FOBT, FIT, mt-sDNA, colonoscopy, prior CTC, flexible sigmoidoscopy).
Colonoscopy is the preferred initial test in symptomatic or high-prevalence populations; CTC may be used historically as an alternative when other CRC screening tests were not performed within intervals or when colonoscopy is not feasible.

When used as an alternative to colonoscopy, prior authorization for CT colonography may be required and documentation that colonoscopy was not feasible or was incomplete is recommended.

Provide documentation of contraindications, failed colonoscopy, or other reasons colonoscopy could not be performed.

Prior Authorization

CTC requires medical necessity per policy; prior auth processes may apply

Medical necessity per the Policy section must be met for CT colonography; payer prior authorization processes may apply according to the member contract.

Confirm prior authorization requirements and that clinical indications meet Policy A or B before performing CTC.

inv-38: CT Colonography (CTC) — key definition

CT Colonography (CTC) — purposeA CT-based imaging test to evaluate the colon for polyps and colorectal cancer; used for screening and to evaluate individuals with positive screening tests or symptoms when colonoscopy is not feasible.

inv-39: CT colonography (CTC) — additional definition / prep notes

CTC procedural notesCTC requires full bowel preparation and gas insufflation; no sedation is required. It may be performed with or without intravenous contrast depending on indication and CPT code.

inv-40: Clinical utility — definition

Clinical utilityClinical utility is defined as producing test results that inform management decisions that improve net health outcomes, e.g., guiding appropriate use of colonoscopy when findings require confirmation.

inv-41: CT colonography (CTC) / Virtual colonoscopy — computed tomographic imaging definition

CTC / Virtual colonoscopy definitionComputed tomographic imaging of the colon performed with thin-section helical CT and image postprocessing (CPT codes 74261–74263) to produce 2D and 3D images for diagnostic or screening purposes; may be done with or without contrast.

Billing Rule

CTC can be with or without IV contrast — choose CPT code accordingly (74261/74262/74263)

CT colonography may be performed with or without intravenous contrast depending on code and clinical indication; use CPT 74261 for without contrast and CPT 74262 when contrast images are included.

Select CPT 74263 for screening CTC when appropriate and ensure documentation matches the code's clinical indication.

Document updated with edits to Description, Rationale, and References sections; policy page archived and no further scheduled review noted.