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    v1.0.28
    OpenPayerPolicy UpdatesGastroenterologymediviewcurative Colonoscopy Coverage Update | Ope…
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    CurrentmediviewcurativePolicy MM-PNP-006

    Colonoscopy and Colorectal Screening

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    Clinical policy governing medical necessity and coverage criteria for colorectal cancer screening, surveillance, and diagnostic colonoscopy-related procedures for members managed by the Medical UM Department.

    Policy Summary
    Payermediviewcurative
    PolicyColonoscopy and Colorectal Screening
    Policy CodePolicy MM-PNP-006
    Change TypeNo material change
    Effective DateOct 16, 2023
    Next Review DateN/A
    Key ActionObtain Medical UM authorization when required by the Medical UM department for screening, high-risk testing, surveillance, diagnostic testing, and biopsies per policy criteria.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    45 yearsScreening begins (average-risk)
    10 yrsColonoscopy interval (average-risk)
    Every yearFOBT interval
    Every 2 yrsHigh-risk/surveillance interval

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Coverage and Medical Necessity Criteria

    Routine Screening

    Covered when ALL of the following are met:

    Average-risk screening

    • Acceptable screening modalities: Colonoscopy every 10 years OR CT colonography every 5 years OR DCBE every 5 years OR FOBT yearly OR Sigmoidoscopy every 5 years OR Sigmoidoscopy every 5 years with annual FOBT OR Stool DNA (FIT-DNA) every 3 yearssee modality-specific interval

    High-Risk Testing

    Covered when ANY of the following high-risk conditions are present (testing may be as frequent as every 2 years):

    High-risk indications: First-degree relative with colorectal cancer or adenomatous polyps (screening begin age 40 or 10 years younger than earliest family diagnosis), OR family history of familial adenomatous polyposis (begin at puberty), OR family history of hereditary non-polyposis colorectal cancer (HNPCC) (begin at age 20), OR family history of MYH-associated polyposis in siblings (begin at age 25), OR diagnosis of Cowden syndrome (begin at age 35)screening as frequently as every 2 years

    Annual FOBT alone or with sigmoidoscopy is considered medically necessary for these members.

    Surveillance

    Covered when ANY of the following surveillance conditions are present (surveillance intervals vary):

    Surveillance indications: Inflammatory bowel disease (including ulcerative colitis or Crohn's disease) — surveillance as frequently as every year; Personal history of adenomatous polyps — surveillance as frequently as every 2 years; Personal history of colorectal cancer — surveillance as frequently as every yearsee indication-specific interval

    Annual FOBT alone or with sigmoidoscopy is considered medically necessary for surveillance.

    Diagnostic Testing

    Covered when members have signs or symptoms suggesting colorectal or other GI disease:

    Diagnostic indications: Diagnostic testing with FOBT, colonoscopy, sigmoidoscopy and/or DCBE is medically necessary for evaluation of signs or symptoms of colorectal cancer or other gastrointestinal diseases; diagnostic upper endoscopy is medically necessary for evaluation of persons with signs and symptoms of upper gastrointestinal diseasesymptomatic

    Biopsy of the Lower Gastro-Intestinal Tract

    Biopsy procedures are considered medically necessary for specified indications with procedural specimen-count/location requirements:

    Biopsy indications and specimen requirements: Microscopic colitis: 8 or more biopsies (2 or more from ascending, transverse, descending, and sigmoid colon); Inflammatory bowel disease, diagnosis: 2 or more biopsies from 5 different locations including the ileum and rectum; IBD dysplasia screening: targeted biopsies plus pancolitis — biopsies from the 4 quadrants every 10 cm; segmental colitis — biopsies from the 4 quadrants every 10 cm limited to involved areas; Pouchitis: multiple biopsies from the pouch and afferent loop; Colonic polyps: biopsies of polyps that cannot be removed; Acute graft-versus-host disease: flexible sigmoidoscopy — 4 or more biopsies from rectum/sigmoid and 4 or more from left colon; ileocolonoscopy — 4 or more biopsies from terminal ileum, ascending colon, transverse colon, descending colon, and rectum/sigmoid colonspecified specimen counts/locations

    The following colorectal cancer screening approaches are considered experimental and investigational because their effectiveness has not been established: stool molecular genetic tests other than Cologuard (for example, ColoCaller, ColoSure, PreGen-Plus); methylated Septin 9 tests (ColoVantage, Epi proColon) and other whole-blood DNA methylation markers; microRNAs; chromoendoscopy or narrow-band imaging during optical colonoscopy; plasma/serum biomarkers (including C-reactive protein, complement C3a anaphylatoxin, plasma GATA5 and SFRP2 methylation, serum CD26, serum MMP-7, TIMP-1); PolypDx and similar metabolomic tests; CD3 immuno-staining; full-spectrum endoscopy (FUSE) colonoscopy; stool- or blood-based protein biomarkers; capsule endoscopy; artificial intelligence–aided (computer-aided) colonoscopy; SimpliPro Colon Test; fecal volatile organic compounds; and performance of multiple screening strategies simultaneously in the same individual (for example, CT colonography plus stool DNA).

    Routine colorectal cancer screening for members 85 years of age or older is considered not medically necessary unless the member’s life expectancy is greater than or equal to 10 years.

    Average-risk definition — Asymptomatic adults without family history of high-risk genetic disorders, personal history of inflammatory bowel disease, prior adenomat..."},{
    DefinitionAsymptomatic adults without family history of high-risk genetic disorders (e.g., Lynch syndrome, familial adenomatous polyposis), without personal history of inflammatory bowel disease, prior adenomatous polyps, or prior colorectal cancer; USPSTF guidance applies to this group.
    Age thresholdAverage-risk screening begins at age 45 years and older (physician-recommended).
    Screening modalities (examples)Acceptable modalities include colonoscopy, CT colonography, double-contrast barium enema (DCBE), fecal occult blood testing (FOBT), sigmoidoscopy, and stool DNA (FIT-DNA/Cologuard).
    Interval guidance (modalities)Colonoscopy every 10 years; CT colonography every 5 years; DCBE every 5 years; FOBT yearly; Sigmoidoscopy every 5 years (or every 5 years with annual FOBT); Stool DNA every 3 years.
    LimitationsRoutine screening is not medically necessary for members 85 years of age or older unless life expectancy is ≥10 years.

    Provider Responsibilities, Prior Authorization, and Documentation

    Prior Authorization

    Obtain Medical UM authorization when required

    Medical management/Utilization Management (Medical UM) governs authorization of colorectal screening and colonoscopy services per the policy criteria; providers must obtain authorization when required by Medical UM processes for screening, high‑risk testing, surveillance, diagnostic testing, and biopsies that meet these criteria.

    Step Therapy

    No step therapy — use any accepted screening modality

    There are no step therapy prerequisites specified in this policy; multiple screening modalities are accepted with defined intervals (e.g., colonoscopy every 10 years; CT colonography or DCBE every 5 years; annual FOBT; sigmoidoscopy every 5 years; FIT‑DNA every 3 years).

    Documentation Required

    Record biopsy counts and exact anatomic locations

    Document procedural biopsy specimen counts and anatomical locations exactly as required by indication: for microscopic colitis obtain 8 or more biopsies (at least 2 each from ascending, transverse, descending, and sigmoid); for IBD diagnosis obtain 2 or more biopsies from five different locations including the ileum and rectum; for dysplasia surveillance follow targeted biopsies plus pancolitis or segmental/ pouch protocols; for acute GVHD obtain specified quadrant/segment biopsies for sigmoidoscopy or ileocolonoscopy.

    • Microscopic colitis: 8+ biopsies (≥2 from ascending, transverse, descending, sigmoid).
    • IBD diagnosis: ≥2 biopsies from 5 locations including ileum and rectum.
    • IBD dysplasia screening: targeted biopsies plus pancolitis — 4‑quadrant biopsies every 10 cm.
    • Segmental colitis: 4‑quadrant biopsies every 10 cm limited to involved areas.
    • Pouchitis: multiple biopsies from pouch and afferent loop.
    • Colonic polyps: biopsy polyps that cannot be removed.
    • Acute graft‑versus‑host disease: flexible sigmoidoscopy — ≥4 biopsies from rectum/sigmoid and ≥4 from left colon; ileocolonoscopy — ≥4 biopsies from terminal ileum, each colon segment, and rectum/sigmoid.
    Denial Risk

    Avoid screening age ≥85 without life‑expectancy documentation

    Routine colorectal cancer screening for members age 85 years or older is considered not medically necessary unless the member’s life expectancy is greater than or equal to 10 years; performing routine screening without documentation supporting life expectancy ≥10 years risks denial.

    Key Terms and Definitions

    Average-risk — Asymptomatic adults without family history of high-risk genetic disorders, personal history of inflammatory bowel disease, prior adenomat...
    Average-risk summaryAsymptomatic adults without family history of high-risk genetic disorders, no personal history of inflammatory bowel disease, no prior adenomatous polyps, and no prior colorectal cancer.
    USPSTF applicabilityUSPSTF guidelines apply to routine screening for this group; their definition excludes those with high-risk genetic disorders, IBD, prior adenomas, or prior colorectal cancer.
    Physician recommendationScreening is considered medically necessary when recommended by the physician for members meeting average-risk criteria.
    Common screening testsIncluded tests: colonoscopy, CT colonography, DCBE, FOBT, sigmoidoscopy, and stool DNA (FIT-DNA/Cologuard).
    Frequency noteFollow-up changes to surveillance recommendations if screening results in diagnosis of adenomas or colorectal cancer; routine screening recommendations then no longer apply.

    Background and Rationale

    Colorectal cancer screening modalities addressed in this policy include colonoscopy, CT colonography (virtual colonoscopy), double-contrast barium enema (DCBE), sigmoidoscopy, fecal occult blood testing (FOBT), and stool DNA (FIT-DNA, e.g., Cologuard). Recommended routine screening intervals for average-risk, asymptomatic adults beginning at age 45 years are: colonoscopy every 10 years; CT colonography every 5 years; DCBE every 5 years; sigmoidoscopy every 5 years (or sigmoidoscopy every 5 years with annual FOBT); FOBT annually; and stool DNA every 3 years. The U.S. Preventive Services Task Force (USPSTF) guidance is referenced for routine screening applicability.

    Policy Summary
    Payermediviewcurative
    PolicyColonoscopy and Colorectal Screening
    Policy CodePolicy MM-PNP-006
    Change TypeNo material change
    Effective DateOct 16, 2023
    Next Review DateN/A
    Key ActionObtain Medical UM authorization when required by the Medical UM department for screening, high-risk testing, surveillance, diagnostic testing, and biopsies per policy criteria.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaProvider Responsibilities, Prior Authorization, and DocumentationKey Terms and DefinitionsBackground and Rationale