priority health colorectal screening Coverage Update

Coverage Criteria

Average-risk screening coverage

Covered preventive screening for average-risk population when ALL of the following apply

Age and risk: Patient is age 45-75 and is average risk as defined (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease; no family history of colorectal cancer or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).age 45-75

Average risk definition per policy

Acceptable screening modalities and intervals: Any one of: colonoscopy once every 10 years; flexible sigmoidoscopy once every 5 years; annual FIT/FOBT; sDNA-FIT (Cologuard) once every 3 years (Cologuard requires the listed criteria); computed tomographic colonography (CTC) when EviCore criteria are met and prior authorization obtained; blood-based or other advanced assays managed by EviCore per Lab Management Program when EviCore criteria are met.intervals specified

See modality-specific requirements and EviCore-managed tests for prior authorization and medical necessity

Services requiring prior authorization and medical necessity review

Coverage and medical necessity overview

Prior authorization for managed services: CT colonography (CPT 74263) and specified advanced blood- or stool-based assays (examples: CPT 81327 SEPT9; 0464U Cologuard Plus; 0537U Shield) require prior authorization and medical necessity review by EviCore. Services managed by EviCore must follow EviCore authorization criteria and Priority Health authorization procedures.

Access EviCore clinical guidelines via Priority Health Prism -> Authorizations -> Authorization Criteria Lookup; out-of-network prior auth requested through Priority Health.

Magnetic resonance imaging colonography (MRI colonography) is considered experimental and investigational and is not covered for the screening or diagnosis of colorectal cancer, inflammatory bowel disease, or other indications because its value for these indications has not been established.

Wireless Capsule Endoscopy (WCE; e.g., PillCam) is considered not medically necessary for general screening and therefore is not covered as a routine colorectal cancer screening modality.

The following blood-based colorectal cancer screening assays are not covered / considered experimental and investigational: BeScreened™-CRC (CPT 0163U) and IGoCheck™ (CPT 0558U). These tests have not been cleared, approved, or authorized by the FDA and are listed as not covered.

Shield™ (0537U) and other advanced blood- or cfDNA-based assays are subject to prior authorization and management by EviCore; coverage decisions for such novel assays follow medical necessity review and program criteria.

Wireless Capsule Endoscopy (WCE; PillCam) is specifically addressed as not medically necessary for general screening and therefore is not an appropriate covered modality for routine average‑risk colorectal cancer screening.

Specific blood-based tests are explicitly identified as not covered / experimental: BeScreened™-CRC (CPT 0163U) and IGoCheck™ (CPT 0558U) are listed as investigational and not covered.

Other novel or advanced blood-based assays (for example, SEPT9 assays and cfDNA-based tests such as Shield™) are managed by EviCore under the Lab Management Program and require prior authorization; such tests may be considered investigational or require additional review before coverage is determined.

Coding

ICD-10 Codes supporting preventive benefitICD-10

Z12.11	Encounter for screening for malignant neoplasm of colon
Z12.12	Encounter for screening for malignant neoplasm of rectum
Z80.0	Family history of malignant neoplasm of digestive organs
Z83.710	Family history of colonic polyps
Z85.00	Personal history of malignant neoplasm of unspecified digestive organ

CPT/HCPCS Procedure CodesCPT | HCPCSCovered

45330	Sigmoidoscopy, flexible; diagnostic
45331	Sigmoidoscopy, flexible; with biopsy
45333	Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45334	Sigmoidoscopy, flexible; with control of bleeding, any method
45335
45338	Sigmoidoscopy, flexible; with removal ... by snare technique
45346	Sigmoidoscopy, flexible; with ablation
45378	Colonoscopy, flexible; diagnostic
45380	Colonoscopy, flexible; with biopsy, single or multiple
45381	Colonoscopy, flexible; with directed submucosal injection(s), any substance

1–10 of 19

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Sigmoidoscopy CPT codesCPTCovered

45330	Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
45331	Sigmoidoscopy, flexible; with biopsy, single or multiple
45333	Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45334	Sigmoidoscopy, flexible; with control of bleeding, any method
45335
45338	Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45346	Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s)

Colonoscopy and screening CPT/HCPCS codesmixedCovered

45378	Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
45380	Colonoscopy, flexible; with biopsy, single or multiple
45381	Colonoscopy, flexible; with directed submucosal injection(s), any substance
45382	Colonoscopy, flexible; with control of bleeding, any method
45384	Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45385	Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45388	Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
45390	Colonoscopy, flexible; with endoscopic mucosal resection
G0104	Colorectal cancer screening; flexible sigmoidoscopy
G0105	Colonoscopy on individual at high risk

1–10 of 12

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Stool and related screening codesmixedCovered

82270	Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening
82274	Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations
G0327	Colorectal cancer screening; blood-based biomarker
G0328	Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous determinations
S0285	Colonoscopy consultation performed prior to a screening colonoscopy procedure

Imaging and advanced molecular assay codes (managed or non-covered)mixed

74263	Computed tomographic (CT) colonography, screening, including image post processing
81327	SEPT9 (Septin9) (eg, colorectal cancer) promoter methylation analysis
0464U	Oncology (colorectal) screening ... [Cologuard Plus™ (Exact Sciences Corp.)]
0537U	Oncology (colorectal cancer), analysis of cell-free DNA (cfDNA) for epigenomic patterns ... [Shield™ (Guardant Health, Inc.)]
0163U	Oncology (colorectal) screening, biochemical enzyme-linked immunosorbent assay ... [BeScreened™-CRC (Beacon Biomedical Inc)]
0558U	Oncology (colorectal), quantitative enzyme-linked immunosorbent assay (ELISA) ... [IGoCheck™ (Milagen, Inc.)]

ICD-10 codes supporting preventive benefitICD-10

Z00.00	Encounter for general adult medical examination without abnormal findings
Z00.01	Encounter for general adult medical examination with abnormal findings

Medicare preventive qualification for CT colonography

Medicare preventive qualificationCPT 74263 (CT colonography, screening) is covered as a preventive service for Medicare effective 1/1/25 (qualifies for the preventive benefit only for plans that cover this service)

EviCore reviewCT colonography may be considered medically necessary and covered when EviCore abdomen imaging criteria are met

Authorization routePrior authorization and medical necessity review for CTC are provided by EviCore via Priority Health Prism

Provider Actions / Prior Authorization

Prior Authorization

Prior Authorization Required for CTC

Computed tomography colonography (CTC) requires prior authorization through EviCore. Providers must request prior authorization in advance via Priority Health Prism (Authorizations → Authorization Criteria Lookup). Lack of the required EviCore authorization may result in claim denial.

CT colonography (74263) — prior authorization required through EviCore
Request prior authorization via Priority Health Prism → Authorizations → Authorization Criteria Lookup
Out-of-network providers should request prior authorization through Priority Health

Prior Authorization

EviCore-Managed Tests Require Prior Authorization

Certain blood- or stool-based advanced assays used for colorectal cancer screening are managed by EviCore and require prior authorization and clinical review. Examples include SEPT9 (81327), Cologuard Plus™ (0464U), Shield™ (0537U), and other lab-managed tests listed under the Lab Management Program. Providers must submit prior authorization requests to EviCore (via Priority Health Prism) when ordering these assays.

Background

Colorectal cancer is a leading cause of cancer death; widespread screening reduces mortality by detecting colorectal cancer and adenomatous polyps at earlier, more treatable stages. Screening options include invasive tests such as colonoscopy (the gold standard) and flexible sigmoidoscopy, as well as noninvasive stool- and blood-based tests with varying sensitivity and specificity.

Routine preventive screening is targeted to the average‑risk population (defined as individuals with no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease and no qualifying family history) and follows established age and interval recommendations to maximize preventive benefit.

Definitions

Average risk

Definition (Average risk)No personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease; no family history of colorectal cancer or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer.

Screening start ageBegin screening at age 45 for average-risk adults

ScopeApplies to both men and women at average risk

Colonoscopy

Definition (Colonoscopy)An endoscopic procedure using a colonoscope to inspect the rectum and colon; can detect irritated or swollen tissue, ulcers, polyps, and cancer and is considered the gold standard for screening.

Clinical utilityMost complete screening procedure; detects tissue abnormalities and allows diagnostic/therapeutic interventions (e.g., biopsy, polypectomy)

Colorectal cancer screening

Coverage Criteria

Coding

Provider Actions / Prior Authorization

Background

Definitions