CurrentBlue KCPolicy POL-PP-268

Colorectal Cancer Screening Payment Policy

Defines Blue KC's reimbursement stance for colorectal cancer screening tests and which providers/lines of business are impacted.

Policy Summary

PayerBlue KC

PolicyColorectal Cancer Screening Payment Policy

Policy CodePolicy POL-PP-268

Change TypeNo material changes

Effective Date07/01/2025

Next Review Date07/01/2026

Key ActionVerify member eligibility and benefits for the date of service before applying coverage criteria; annual FIT or gFOBT screening reimbursable for asymptomatic individuals 45–75.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

45-75age range

over 75age not routinely reimbursed

07/01/2025Effective

POL-PP-268ID

Colorectal Cancer Screening Coverage Criteria

Colorectal cancer screening coverage criteria

Coverage is dependent on member benefit and date of service. Specific stances follow:

Apply coverage criteria based on the member's benefit coverage at the time of the request.

Ages 45-75

Ages 45-75: For asymptomatic individuals 45 to 75 years of age, annual screening for colorectal cancer with a fecal immunochemical test (FIT) (preferred) or a guaiac fecal occult blood test (gFOBT) may be reimbursed.
Methylated Septin 9 (ColoVantage) and FIT-DNA (Cologuard) may be reimbursed for colorectal cancer screening.

Over 75: For average-risk, asymptomatic individuals over 75 years of age, colorectal cancer screening may not be reimbursed.

Policy Summary

PayerBlue KC

PolicyColorectal Cancer Screening Payment Policy

Policy CodePolicy POL-PP-268

Change TypeNo material changes

Effective Date07/01/2025

Next Review Date07/01/2026

Key ActionVerify member eligibility and benefits for the date of service before applying coverage criteria; annual FIT or gFOBT screening reimbursable for asymptomatic individuals 45–75.

SourceLink

On This Page

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.

Coding and Age Thresholds

Listed lab and infectious disease CPT CodesCPT

86318	Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip).
86328	Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
86408	Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID19]); screen.
86409	Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID19]); titer.
86413	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative.
86769	Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]).
87426	Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA],
87428	enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA],.
87631	Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus ..., includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.
87632	Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus ..., includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets.

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Age threshold for routine screening reimbursement

Age range for routine reimbursable screening45-75 years

Reimbursement frequency within age rangeAnnual screening may be reimbursed

ApplicabilityAsymptomatic individuals only

Benefit verificationCoverage dependent on member's benefit at time of request

Provider Actions and Coverage Application

Documentation Required

Apply coverage based on member benefits and age thresholds for CRC screening

Verify member eligibility and benefits for the date of service before applying coverage for colorectal cancer screening. Annual screening for asymptomatic individuals aged 45–75 with a fecal immunochemical test (FIT) (preferred) or a guaiac fecal occult blood test (gFOBT) may be reimbursed; methylated Septin 9 (ColoVantage) or FIT‑DNA (Cologuard) may also be reimbursed. For average‑risk, asymptomatic individuals over age 75, screening may not be reimbursed. Do not bill for anal cytological screening (anal pap smear) or screening for anal HPV infection as colorectal cancer screening under this policy.

Confirm member benefit coverage and date of service eligibility prior to ordering or billing.
Reimbursable routine screening age range: 45–75 years; FIT preferred, gFOBT acceptable.
ColoVantage (methylated Septin 9) and Cologuard (FIT‑DNA) may be reimbursed per policy.
Average‑risk, asymptomatic individuals >75 years: screening may not be reimbursed—check benefits or document clinical justification if applicable.
Anal pap smear and anal HPV screening do not meet coverage criteria and should not be billed as colorectal cancer screening.

Key Definitions

Colorectal cancer (CRC) definition

DefinitionColorectal cancer (CRC) — development of cancer in the colon or the rectum

Grouping rationaleColon and rectal cancer are grouped because they share similar characteristics and features

Screening purposeScreening detects colorectal cancer early and significantly impacts incidence and mortality

Screening tests

Preferred stool-based testsFecal immunochemical test (FIT) — preferred for annual screening

Alternate stool-based testGuaiac fecal occult blood test (gFOBT) — may be reimbursed

Blood-based test referencedMethylated Septin 9 (ColoVantage) — may be reimbursed

Multitarget stool DNA testFIT-DNA (Cologuard) — may be reimbursed