ModifiedHealthfirstPolicy PO-RE-080v5

Colorectal Cancer Screening Reimbursement Policy

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This policy governs Healthfirst coverage criteria for colorectal cancer screening tests, including eligible populations, testing intervals, preferred modalities, and tests that do not meet coverage criteria. Coverage depends on the member's benefit plan; Medicare and Medicaid specifications are addressed elsewhere in the policy.

Policy Summary

PayerHealthfirst

PolicyColorectal Cancer Screening Reimbursement Policy

Policy CodePolicy PO-RE-080v5

Change TypeModified

Effective DateNov 1, 2026

Next Review DateN/A

Key ActionDocument the patient's age, symptoms, screening history, life expectancy, personal and family colorectal cancer risk, and the rationale for individualized screening decisions in adults older than 75 years.

SourceLink

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ModifiedHealthfirstPolicy PO-RE-080v5

Colorectal Cancer Screening Reimbursement Policy

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Policy Summary

PayerHealthfirst

PolicyColorectal Cancer Screening Reimbursement Policy

Policy CodePolicy PO-RE-080v5

Change TypeModified

Effective DateNov 1, 2026

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

Coverage criteria were added for asymptomatic individuals ages 45 through 75 to receive multi-target stool DNA or multi-target stool RNA screening once every three years.

A coverage limitation was added for asymptomatic individuals ages 45 through 75 who already received a multi-target stool-based test within the previous three years.

CPT code 0421U was added to the applicable colorectal cancer screening codes.

CPT code 87626 was added and the description for CPT code 87624 was revised.

CPT code 0537U was revised and CPT code 0500T was removed because the latter code was deleted.

45-75 yearsCovered screening age range

AnnuallyCovered FIT or gFOBT interval

Every 3 yearsCovered FIT-DNA interval

>75 yearsAverage-risk screening not covered over

Not coveredCologuard Plus Medicaid coverage

Colorectal Cancer Screening Coverage Criteria

Covered stool-based screening

Covered when the individual is asymptomatic and 45 to 75 years of age.

Annual FIT or gFOBT screening: Annual colorectal cancer screening with a fecal immunochemical test (FIT), preferred, or a guaiac fecal occult blood test (gFOBT) meets coverage criteria.Annual

FIT is preferred over gFOBT.

Covered FIT-DNA screening

Covered for average-risk, asymptomatic individuals aged 45 to 75 years.

FIT-DNA screening: Colorectal cancer screening using FIT-DNA, including Cologuard or Cologuard Plus, meets coverage criteria once every three years.Every 3 years

High-risk individuals are excluded from this criterion.

Repeat or alternate multitarget testing

Does not meet coverage criteria when a multitarget stool-based test was performed within the last three years.

Alternate multitarget stool test too soon: For an asymptomatic individual aged 45 to 75 years, use of a different approved multitarget stool-based test does not meet coverage criteria if a multitarget stool-based test has already been performed in the last three years.Prior test within 3 years

The restriction applies to use of a different approved multitarget stool-based test.

Not covered screening modalities

The following screening services do not meet coverage criteria.

Non-covered screening modalities: Methylated Septin 9 screening, anal cytological abnormality screening, anal HPV screening, and cell-free DNA screening techniques such as Guardant Shield do not meet coverage criteria.

The policy cites lack of published scientific literature confirming that these tests are required and beneficial for diagnosis and treatment.

Screening over age 75

Does not meet coverage criteria for average-risk, asymptomatic individuals over 75 years of age.

Age over 75: Colorectal cancer screening does not meet coverage criteria for average-risk, asymptomatic individuals older than 75 years.>75 years

This criterion applies to average-risk asymptomatic individuals.

Average-risk screening by age

Guideline-supported screening recommendations for average-risk adults.

Average-risk screening: Screening is recommended beginning at age 45 and through age 75 when clinically appropriate; screening from ages 76 through 85 should be individualized based on health status, life expectancy, prior screening, colorectal cancer risk, and patient preference; screening is not recommended after age 85.Age 45-75 routine screening; age 76-85 individualized; over age 85 not recommended

Recommendations are drawn from USPSTF, ACS, ACG, U.S. Multi-Society Task Force, and NCCN guidance.

Screening modality intervals

Screening modality and interval recommendations.

Acceptable screening modalities: Recommended options include annual FIT or high-sensitivity gFOBT, sDNA-FIT every 1 to 3 years, colonoscopy every 10 years, CT colonography every 5 years, flexible sigmoidoscopy every 5 years, or flexible sigmoidoscopy combined with FIT according to the applicable guideline strategy.FIT/gFOBT annually; sDNA-FIT every 1-3 years; colonoscopy every 10 years; CT colonography every 5 years; flexible sigmoidoscopy every 5 years

The ACG identifies colonoscopy and FIT as primary modalities and suggests other modalities when patients are unable or unwilling to undergo colonoscopy or FIT.

Family-history screening

Additional screening criteria for family history.

Family-history pathways: For colorectal cancer or an advanced polyp in one first-degree relative before age 60, or in at least two first-degree relatives at any age, begin colonoscopy at age 40 or 10 years before the youngest affected relative, whichever is earlier, and repeat every 5 years. For one first-degree relative affected at age 60 or older, begin screening at age 40 or 10 years before the youngest affected relative and then resume average-risk recommendations. For one second-degree relative with colorectal cancer or an advanced polyp, follow average-risk recommendations.Age 40 or 10 years before youngest affected relative; 5-year colonoscopy interval for specified higher-risk family history

Consider genetic evaluation when the familial colorectal cancer burden is higher.

Positive screening test follow-up

Follow-up and test-use criteria.

Abnormal non-colonoscopy screening result: A positive FIT, multitarget stool DNA, Epi proColon, or other non-colonoscopy screening result should be followed by diagnostic colonoscopy.Follow-up colonoscopy after a positive result

If colonoscopy after FIT or multitarget stool DNA is negative, high quality, and the patient has no symptoms, average-risk screening may resume at 10 years, subject to symptoms and other colorectal cancer risk factors.

Covered multi-target stool DNA or RNA screening

Meets coverage criteria when the individual is asymptomatic, ages 45 through 75, and the screening is performed once every three years.

Covered multi-target stool screening: The individual is asymptomatic; the individual is 45 through 75 years of age; and screening is performed once every three years using a multi-target stool DNA-based test (Cologuard or Cologuard Plus) or a multi-target stool RNA-based test (ColoSense).Age 45-75; once every three years

Different multi-target stool test within three years

Does not meet coverage criteria when all of the following apply.

Repeat or alternate multi-target stool testing: The individual is asymptomatic and 45 through 75 years of age; a multi-target stool-based test was performed within the last three years; and a different approved multi-target stool-based test is used.Prior test within the last three years

FIT-DNA screening, including Cologuard and Cologuard Plus, meets coverage criteria only for average-risk, asymptomatic individuals ages 45 through 75. High-risk individuals are excluded from this coverage criterion.

Cologuard is intended for screening average-risk adults and is not a replacement for diagnostic or surveillance colonoscopy in high-risk individuals. High-risk populations include individuals with a personal history of colorectal cancer or adenomas, a positive colorectal screening result within the last 6 months, inflammatory bowel disease or related conditions, a family history of colorectal cancer, or certain hereditary cancer syndromes.

Cologuard should not be used in place of diagnostic or surveillance colonoscopy for high-risk patients. It is not indicated for patients with prior colorectal cancer, adenomas, or related cancers; a recent positive colorectal screening result; inflammatory bowel disease, chronic ulcerative colitis, Crohn's disease, familial adenomatous polyposis, a family history of colorectal cancer, or relevant hereditary cancer syndromes. A positive result should be followed by diagnostic colonoscopy.

Cologuard Plus is indicated for average-risk adults and meets coverage criteria for asymptomatic individuals ages 45 through 75 when performed once every 3 years. It is not indicated for patients with a personal history of colorectal cancer or advanced precancerous lesions, a recent positive colorectal screening result, a first-degree family history of colorectal cancer, inflammatory bowel disease, or hereditary cancer or polyposis syndromes. A positive result should be followed by colonoscopy.

Screening using cell-free DNA techniques, including Guardant Shield, does not meet coverage criteria. The policy identifies this modality as excluded because available published scientific literature does not confirm that these tests are required and beneficial for diagnosis and treatment.

Applicable Codes and Screening Parameters

Applicable CodesCPT

81327	SEPT9 (Septin9) (eg, colorectal cancer) promoter methylation analysis.
81528	Oncology (colorectal) screening, quantitative real-time target, and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result.
82274	Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations.
87624	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68), pooled result.
87625	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed.
87626	Infectious agent detection by nucleic acid (DNA or RNA); separately reported high-risk types (eg, 16, 18, 31, 45, 51, 52), and high-risk pooled result(s).
88112	Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid-based slide preparation method), except cervical or vaginal.
0421U	Oncology (colorectal) screening, quantitative real-time target and signal amplification of 8 RNA markers (GAPDH, SMAD4, ACY1, AREG, CDH1, KRAS, TNFRSF10B, EGLN2) and fecal hemoglobin, algorithm reported as a positive or negative for colorectal cancer risk. Proprietary Test: Colosense™; Lab/Manufacturer: Geneoscopy, Inc.
0464U	Oncology (colorectal) screening, quantitative real-time target and signal amplification, methylated DNA markers, including LASS4, LRRC4 and PPP2R5C, a reference marker ZDHHC1, and a protein marker (fecal hemoglobin), utilizing stool, algorithm reported as a positive or negative result. Proprietary Test: Cologuard Plus™; Lab/Manufacturer: Exact Sciences Laboratories, LLC, Exact Sciences Corporation.
0537U	Oncology (colorectal cancer), analysis of cell-free DNA for epigenomic patterns, next-generation sequencing, >2500 differentially methylated regions (DMRs), plasma, algorithm reported as positive or negative. Proprietary Test: Shield™; Lab/Manufacturer: Guardant Health, Inc.

Applicable CodesCPT

88112

Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid-based slide preparation method), except cervical or vaginal

Applicable CodesCPT

0421U	Oncology (colorectal) screening, quantitative real-time target and signal amplification of 8 RNA markers (GAPDH, SMAD4, ACY1, AREG, CDH1, KRAS, TNFRSF10B, EGLN2) and fecal hemoglobin, algorithm reported as a positive or negative for colorectal cancer risk
0464U	Oncology (colorectal) screening, quantitative real-time target and signal amplification, methylated DNA markers, including LASS4, LRRC4 and PPP2R5C, a reference marker ZDHHC1, and a protein marker (fecal hemoglobin), utilizing stool, algorithm reported as a positive or negative result
0537U	Oncology (colorectal cancer), analysis of cell-free DNA for epigenomic patterns, next-generation sequencing, >2500 differentially methylated regions (DMRs), plasma, algorithm reported as positive or negative

Screening threshold

Screening age45 through 75 years

PopulationAsymptomatic individuals

Covered test typesMulti-target stool DNA-based or multi-target stool RNA-based tests

Multi-target stool DNA or RNA screening

Screening frequencyOnce every three years

DNA-based testsCologuard or Cologuard Plus

RNA-based test

Provider Documentation and Action Items

Documentation Required

Risk Assessment and Screening Status

Conduct colorectal cancer screening through a preventive visit that includes an individual risk assessment. Confirm and document the patient's symptoms and current screening status before selecting a screening approach.

Assess whether the patient is asymptomatic or has symptoms requiring diagnostic evaluation rather than screening.
Record prior screening, including the type and date of the most recent test.

Documentation Required

Record Screening Risk and Clinical Rationale

Document the clinical factors supporting the screening decision, including age, symptoms, personal and family history, prior screening, life expectancy, comorbidities, CRC risk, and patient preference. Record the rationale for initiating, continuing, individualizing, or stopping screening, particularly for patients ages 76–85.

Average-risk screening is generally recommended from ages 45–75 when life expectancy is at least 10 years.
Individualize screening from ages 76–85 using overall health, comorbidity status, prior screening history, life expectancy, CRC risk, and patient preference.

Colorectal Cancer Screening Background

Colorectal cancer develops in the colon or rectum. Screening is intended to detect colorectal cancer and adenomatous polyps at an earlier stage, when detection and treatment may be more effective. Screening decisions generally follow an assessment of personal and family history and other risk factors, often during an annual wellness visit. Available screening modalities include stool-based tests and CT colonography; this policy focuses primarily on FIT, gFOBT, and FIT-DNA criteria.

Key Terms

Colorectal cancer (CRC)

DefinitionCancer that develops in the colon or rectum

Anatomic sitesColon and rectum

Related termsColon cancer and rectal cancer are often grouped together because they share similar characteristics and features

Fecal immunochemical test (FIT)

Test typeStool-based test

What it measuresHemoglobin directly in the stool

Sample collectionThe patient places a stool sample in a specimen collection kit; FIT generally requires one sample

Policy Summary

PayerHealthfirst

PolicyColorectal Cancer Screening Reimbursement Policy

Policy CodePolicy PO-RE-080v5

Change TypeModified

Effective DateNov 1, 2026

Next Review DateN/A

SourceLink

On This Page

Prior multi-target stool-based testing

Lookback periodWithin the last three years

Applies toAsymptomatic individuals 45 through 75 years of age

Coverage limitationUse of a different approved multi-target stool-based test does not meet coverage criteria

Patients with rectal bleeding, iron-deficiency anemia, diarrhea, abdominal pain, weight loss, or other CRC-associated symptoms require prompt tailored evaluation, not routine screening.

Billing Rule

Claim Support and Coding Compliance

Support each claim with documentation that establishes the applicable benefit, screening indication, patient risk category, test performed, and clinical rationale. Submit claims consistently with the member's evidence of coverage and applicable state and federal requirements.

Verify the patient's benefit coverage and line of business at the time of service.
Ensure the medical record supports the service billed and the applicable coverage criteria.

Denial Risk

Do Not Repeat or Alternate Multitarget Stool Testing Too Soon

Do not repeat a multitarget stool-based test during the three-year interval merely by switching to a different approved multitarget stool test. For asymptomatic patients ages 45–75, the subsequent alternate test does not meet coverage criteria.

Check the date and type of the prior multitarget stool-based test before ordering another one.
Apply the three-year lookback period to approved multitarget stool-based testing.

Denial Risk

ColoVantage Not Covered

Do not use methylated Septin 9 testing, including ColoVantage, for colorectal cancer screening when seeking coverage under this policy. ColoVantage does not meet coverage criteria.

Methylated Septin 9 (ColoVantage) screening is non-covered.

Denial Risk

Non-Covered Screening Techniques

Do not bill the following techniques as covered colorectal cancer screening because they do not meet coverage criteria: anal cytology, anal HPV screening, or cell-free DNA screening techniques.

Anal cytological abnormality screening, including anal Pap smear, is non-covered.
Anal HPV screening is non-covered.
Cell-free DNA techniques, including Guardant Shield, are non-covered.

Denial Risk

Cologuard Plus Line-of-Business Restriction

Apply the member's line-of-business rules before ordering or billing Cologuard Plus. Medicaid products follow eMedNY coverage guidelines and do not cover Cologuard Plus.

Coverage for Cologuard Plus varies by line of business.
Do not assume commercial coverage rules apply to Medicaid products.

Denial Risk

Do Not Use Cologuard in High-Risk Populations

Use Cologuard only for indicated average-risk screening; it is not a replacement for diagnostic colonoscopy or surveillance colonoscopy in patients with high-risk histories or positive screening results.

Do not use Cologuard for patients with a history of colorectal cancer, adenomas, or related cancers.
Do not use it for patients with inflammatory bowel disease, chronic ulcerative colitis, Crohn's disease, familial adenomatous polyposis, a family history of CRC, or relevant hereditary cancer syndromes.
Refer patients with symptoms, high-risk histories, or positive results for appropriate diagnostic or surveillance care.

Denial Risk

Cologuard Plus Contraindications

Do not use Cologuard Plus for patients in the contraindicated populations identified by the FDA. Confirm personal and family history, high-risk conditions, hereditary syndromes, and recent screening results before ordering.

Exclude a personal history of colorectal cancer or advanced precancerous lesions.
Exclude a positive result from another colorectal screening method within the applicable interval: 6 months generally, 12 months for FOBT/FIT, or 36 months for a FIT-DNA test.
Exclude a first-degree family history of CRC.
Exclude inflammatory bowel disease and hereditary or other polyposis syndromes, including FAP, Lynch syndrome, Peutz-Jeghers, MAP, Turcot's, Cowden's, juvenile polyposis, Cronkhite-Canada, neurofibromatosis, and serrated polyposis.

Prior Authorization

Follow Positive Screening Results With Colonoscopy

A positive non-colonoscopy colorectal cancer screening result requires diagnostic colonoscopy. Do not treat a positive stool-based or blood-based screening result as resolved by repeating the screening test.

Follow positive Cologuard or Cologuard Plus results with colonoscopy.
Follow a positive Epi proColon result with diagnostic colonoscopy.
Use diagnostic or surveillance colonoscopy, as clinically appropriate, for high-risk patients or patients with symptoms.

Denial Risk

Duplicate Multitarget Stool Testing Within Three Years

Do not submit another approved multitarget stool test within three years after a prior multitarget stool-based test, even when the subsequent test is different. Such duplicate testing does not meet coverage criteria and may be denied.

Review the patient's prior three-year testing history before ordering or billing.
Document the test type and date used to apply the lookback rule.

Billing Rule

Coding and Reimbursement Noncompliance

Follow Healthfirst, CMS, NCCI, CPT, HCPCS, ICD-10, revenue coding, modifier, claim-edit, and applicable state-specific billing requirements. Coding, billing, or reimbursement violations may result in claim denial or recoupment.

Apply appropriate modifier usage, global surgery and multiple-procedure rules, medically unlikely edits, and duplicate edits.
Use current AMA, CMS, National Uniform Billing Editor, CPT Assistant, New York State, and applicable specialty coding guidance.
Reimbursement is subject to the applicable evidence of coverage, state and federal requirements, and provider participation agreement.

Guaiac fecal occult blood test (gFOBT)

Test typeStool-based test that detects hemoglobin

Detection methodGuaiac reagent-impregnated paper turns blue through a peroxidase reaction

Sample collectionSamples are collected on a test card from three consecutive bowel movements and mailed to the laboratory

Multi-target stool DNA test (FIT-DNA)

DefinitionComposite test combining a fecal immunochemical test with molecular analysis of stool DNA alterations

ComponentsMolecular assays analyze DNA alterations, while an immunochemical assay measures hemoglobin

Other namessDNA-FIT, MT-sDNA, or FIT-DNA

Average risk

DefinitionIndividuals without the high-risk characteristics described in the test labeling

Examples of excluded characteristicsPersonal history of colorectal cancer or adenomas, recent positive screening, or inflammatory bowel disease

Additional risk factorsCertain family-history and hereditary-syndrome risks are high-risk characteristics