CurrentCurativePolicy CHP-OP-2026-002

Computed Tomographic Colonography

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This policy governs coverage criteria for screening and diagnostic computed tomographic colonography (CTC, or virtual colonoscopy) in adults. It addresses medical necessity, repeat services, follow-up after CTC findings, documentation, coding, safety exclusions, and review requirements.

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CurrentCurativePolicy CHP-OP-2026-002

Computed Tomographic Colonography

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Policy Summary

PayerCurative

PolicyComputed Tomographic Colonography

Policy CodePolicy CHP-OP-2026-002

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit documentation showing the applicable screening, diagnostic, repeat-service, or follow-up criteria for every CTC request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

45-75 yearsPrimary screening age range

Every 5 yearsAverage-risk screening CTC interval

3Applicable CTC billing codes

10 mm+Polyp size requiring optical colonoscopy follow-up

C0-C4 / E0-E4C-RADS reporting categories

Coverage Criteria

Screening CTC

Screening CTC is medically necessary when ALL of the following are met.

Asymptomatic: No rectal bleeding, iron-deficiency anemia, positive stool test, or change in bowel habit under evaluation.
Age and risk pathway
- Average risk: Age 45 to 75 at average risk.45-75 years
- Moderately elevated risk: Age 45 to 75 with moderately elevated risk for which the ordering clinician documents that CTC is an accepted option, such as a single first-degree relative diagnosed with colorectal cancer or advanced adenoma at age 60 or older.45-75 years
- Individualized older-adult decision: Age 76 to 85 with an individualized decision documented, considering overall health, prior screening history, life expectancy, and preferences.76-85 years
Prior screening interval: No screening CTC within the prior 5 years, and no screening colonoscopy within the prior 10 years or flexible sigmoidoscopy or stool DNA test within the applicable interval that remains current.CTC: 5 years; colonoscopy: 10 years
Shared selection and counseling: The member and clinician have selected CTC as the screening strategy, and the member has been informed that a significant finding requires optical colonoscopy.

Diagnostic CTC

Diagnostic CTC, with or without intravenous contrast, is medically necessary when ANY of the following is documented and evaluation of the colon is clinically required.

Diagnostic CTC indications

Incomplete optical colonoscopy: The colonoscopy was incomplete for a reason within the policy definition, and CTC is used to evaluate the unvisualized colon; CTC may be performed the same day or after an interval determined by the endoscopist.
Optical colonoscopy contraindicated or high risk: Optical colonoscopy is medically contraindicated or carries increased sedation, bleeding, perforation, or cardiopulmonary risk that makes CTC preferable, such as high anesthesia risk, non-interruptible anticoagulation, or severe cardiopulmonary disease.
Obstructing or stenosing lesion: A known obstructing or stenosing colonic lesion requires evaluation of the colon proximal to the lesion before surgery.

Follow-up of CTC findings

Follow-up after CTC is managed under ALL of the following.

CTC finding follow-up

Colonoscopy referral for significant colonic findings: Any polyp 10 mm or larger, three or more polyps 6 to 9 mm, or a likely malignant mass (C-RADS C3 or C4) is referred for optical colonoscopy.>=10 mm; or >=3 polyps 6-9 mm; or C3/C4
Intermediate polyp follow-up: One or two polyps 6 to 9 mm (C-RADS C2) are referred for optical colonoscopy or surveillance CTC at about 3 years, as decided by the member and clinician.1-2 polyps 6-9 mm; about 3 years
Positive screening CTC: A follow-up colonoscopy after a positive screening CTC is part of screening under the plan's preventive services standards.

Continuation, repeat service, and re-authorization

Repeat CTC is medically necessary when ANY of the following is met.

Repeat or re-authorization criteria

Screening interval reached: At least 5 years have passed after a negative or C1 screening CTC.>=5 years
C2 surveillance: Surveillance CTC is performed about 3 years after a C2 finding when colonoscopy was declined.about 3 years
Prior inadequate study: The prior CTC was inadequate (C0) because of preparation or distention.C0

CTC is contraindicated or unsafe when there is suspected perforation, acute diverticulitis, fulminant colitis, toxic megacolon, or an immediate postoperative colon. Colonic insufflation may cause harm; use cross-sectional CT under the applicable general CT policy when indicated.

For symptoms suggesting colorectal neoplasia—such as rectal bleeding, iron-deficiency anemia, unexplained weight loss, or a change in bowel habit—or after a positive stool-based test, CTC is not a screening indication. Diagnostic optical colonoscopy is the first-line test.

For members with a hereditary colorectal cancer syndrome, inflammatory bowel disease, or prior colorectal cancer, optical colonoscopy surveillance is preferred. CTC is available only when the diagnostic criteria are met.

Screening CTC in an average-risk member more often than once every 5 years does not meet medical-necessity criteria when there is no new diagnostic indication.

CTC does not meet criteria when a therapeutic intervention, such as biopsy, polypectomy, or hemostasis, is already known to be required and feasible optical colonoscopy can provide the needed treatment.

CTC is not medically necessary and may be unsafe with acute diverticulitis, fulminant colitis, suspected perforation, toxic megacolon, or immediate postoperative risk because colonic insufflation may cause harm.

Screening CTC is not medically necessary as the primary screening test for high-risk members. Optical colonoscopy surveillance is the preferred approach.

Routine CTC during pregnancy does not meet criteria unless an urgent individualized benefit-risk review supports the examination and no safer adequate alternative exists.

Screening CTC in adults older than 85 does not meet medical-necessity criteria.

Coding and Operational Thresholds

CT colonography codesCPT

74261	CT colonography, diagnostic without contrast
74262	CT colonography, diagnostic with contrast
74263	CT colonography, screening

Large or numerous polyps

ThresholdAny polyp >=10 mm, or three or more polyps 6-9 mm

Follow-upRefer for optical colonoscopy

Additional qualifying findingA likely malignant mass classified as C-RADS C3 or C4 also requires optical colonoscopy follow-up

Intermediate-size polyps

ThresholdOne or two polyps 6-9 mm

C-RADS categoryC2

Follow-up optionsOptical colonoscopy or surveillance CTC at about 3 years, as decided by the member and clinician

Provider Documentation and Review Requirements

Prior Authorization

Submit medical-necessity documentation

Requests for computed tomographic colonography must document the applicable screening or diagnostic medical-necessity criteria. Screening requests must include symptoms, age and risk category, prior screening history and intervals, selection of CTC as the strategy, and counseling that significant findings require optical colonoscopy; diagnostic requests must document the qualifying indication and supporting colonoscopy or risk information.

Documentation Required

Document intent and prior screening

Document whether the request is for screening or diagnosis. For screening, include the risk category and dates and results of prior colorectal screening tests.

Documentation Required

Clinical Background

Computed tomographic colonography (CTC), also called virtual colonoscopy, is a noninvasive CT-based examination of the colon. It is an accepted colorectal cancer screening strategy for appropriate adults, generally at five-year intervals, and may also be used diagnostically when optical colonoscopy is incomplete, contraindicated, or carries unacceptable risk.

Definitions and Reporting Framework

Average risk

Personal historyNo personal history of colorectal cancer or adenomatous or advanced serrated polyps

Medical historyNo inflammatory bowel disease; no confirmed or suspected hereditary colorectal cancer syndrome; and no prior abdominal or pelvic radiation for cancer

Family historyNo family history of colorectal cancer meeting high-risk thresholds

Incomplete colonoscopy

ExtentAn optical colonoscopy that did not reach the cecum

VisualizationA colonoscopy that did not adequately visualize the colon

Qualifying causes

Covered Indications

Screening of asymptomatic adults at average or moderately elevated risk

Covered when the following screening eligibility requirements are met.

Screening eligibility: The member is an asymptomatic adult meeting a qualifying age and risk pathway, is within the applicable screening interval, and has selected CTC with understanding that significant findings require optical colonoscopy.Age 45-75 primarily; individualized decision age 76-85

Diagnostic evaluation when optical colonoscopy is incomplete, contraindicated, high risk, or unable to evaluate the proximal colon

Covered when the following diagnostic eligibility requirement is met.

Diagnostic eligibility: Evaluation of the colon is clinically required because optical colonoscopy is incomplete, contraindicated, or carries unacceptable risk; an obstructing or stenosing lesion requires evaluation of the proximal colon before surgery; or a gastroenterologist or surgeon documents a safe, necessary, and appropriately timed special circumstance such as recent colon surgery.

Frequency and Surveillance Limits

Screening computed tomographic colonography

FrequencyOnce every 5 years

PopulationAverage-risk members

Repeat-study benchmarkAt least 5 years after a negative or C1 screening CTC

Surveillance computed tomographic colonography

FindingC2 finding involving one or two polyps 6-9 mm

FrequencyAbout 3 years after the C2 finding

ConditionColonoscopy was declined; optical colonoscopy remains an alternative follow-up option

Prior Authorization Requirements

Prior Authorization

Provide criteria documentation for review

Documentation of the applicable screening, diagnostic, repeat-service, and follow-up criteria is required for review of computed tomographic colonography.

Contrast Administration Rules

Billing Rule

Document the rationale for diagnostic contrast

Diagnostic CTC may be performed with or without intravenous contrast. Intravenous contrast requires a documented diagnostic indication.

Billing Rule

Perform screening CTC without intravenous contrast

Screening CTC is performed without intravenous contrast.

Not Covered Services

Not-covered services include screening magnetic-resonance colonography or other virtual gastrointestinal endoscopy. Routine screening CTC is also not covered for high-risk members when optical colonoscopy surveillance is indicated; CTC may be considered only under applicable diagnostic criteria.

Policy Summary

PayerCurative

PolicyComputed Tomographic Colonography

Policy CodePolicy CHP-OP-2026-002

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit documentation showing the applicable screening, diagnostic, repeat-service, or follow-up criteria for every CTC request.

SourceLink

On This Page

Recent surgery or special circumstance:

A gastroenterologist or surgeon documents that CTC is safe, necessary, and appropriately timed after recent colon surgery or in another special circumstance.

Extracolonic findings: Clinically significant extracolonic findings (C-RADS E3 or E4) are followed according to the applicable imaging or condition policy.E3/E4

Screening CTC interval

Repeat timingAt least 5 years after a negative or C1 screening CTC

Average-risk limitScreening CTC is limited to once every 5 years for average-risk members

Screening modalityScreening CTC is performed without intravenous contrast

Surveillance CTC interval

Eligible findingC2 finding involving one or two polyps 6-9 mm

Surveillance timingAbout 3 years after the C2 finding

ConditionApplies when colonoscopy was declined

Document the diagnostic indication

For diagnostic CTC, include the prior colonoscopy report and extent reached, or the documented contraindication or elevated procedural risk.

Documentation Required

Confirm asymptomatic screening status

For screening requests, document that the member is asymptomatic for colorectal disease, including absence of rectal bleeding, iron-deficiency anemia, a positive stool test, or a change in bowel habit under evaluation.

Documentation Required

Document preparation, contrast, and follow-up

Include the bowel-preparation plan, the contrast plan when diagnostic CTC is requested, and the follow-up plan for positive findings.

Documentation Required

Document the ordering clinician and older-adult decision

Identify the ordering clinician. For members aged 76 to 85, document an individualized screening decision considering overall health, prior screening history, life expectancy, and preferences.

Denial Risk

Avoid excessive screening frequency

Screening CTC more often than every 5 years in an average-risk member without a new diagnostic indication does not meet medical-necessity criteria.

Denial Risk

Use optical colonoscopy when treatment is required

CTC does not meet criteria when biopsy, polypectomy, hemostasis, or another therapeutic intervention is already known to be required and feasible optical colonoscopy would provide the needed treatment.

Denial Risk

Do not perform CTC in unsafe conditions

CTC is not medically necessary and may be unsafe with acute diverticulitis, fulminant colitis, suspected perforation, toxic megacolon, or immediate postoperative risk because colonic insufflation may cause harm.

Denial Risk

Use optical colonoscopy for high-risk screening

Screening CTC is not medically necessary as the primary screening test for high-risk members. Optical colonoscopy surveillance is preferred; CTC is available only under diagnostic criteria.

Denial Risk

Document urgent individualized review during pregnancy

Routine screening CTC during pregnancy does not meet criteria unless an urgent individualized benefit-risk review supports it and no safer adequate alternative exists.

Denial Risk

Do not substitute an unaccepted virtual screening modality

Magnetic-resonance colonography or other virtual gastrointestinal endoscopy is experimental or investigational for screening and is not an accepted USPSTF or ACS screening strategy.

Denial Risk

Screening CTC is not covered over age 85

Screening CTC in adults older than 85 does not meet medical-necessity criteria.

Anatomy, tortuosity or redundancy, stricture, obstructing lesion, intolerance, inadequate preparation, or technical failure

C-RADS

DefinitionCT Colonography Reporting and Data System, a consensus reporting framework

Colonic categoriesC0 inadequate through C4 likely malignant

Extracolonic categoriesE0 through E4

PurposeLinks categories to follow-up

Repeat or surveillance CTC

Covered when the following repeat-service eligibility requirement is met.

Repeat-service eligibility: At least 5 years have passed after a negative or C1 screening CTC; surveillance CTC is performed about 3 years after a C2 finding when colonoscopy was declined; or the prior CTC was inadequate (C0) because of preparation or distention.5 years; about 3 years; or C0 inadequate study