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Clinical Policy Title: Virtual colonoscopy (CT colonography) Clinical Policy Number: CCP.1269

Effective Date: January 1, 2017

Initial Review Date: October 19, 2016

Most Recent Review Date: October 2, 2018

Next Review Date: October 2019

Related policies: CCP.1055 Capsule endoscopy

CCP.1050 Familial polyposis gene testing

CCP.1097 COLARIS® testing for Lynch syndrome

CCP.1319 Colorectal cancer screening

ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas’ clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas’ clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas’ clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas’ clinical policies are not guarantees of payment.

Coverage policy

AmeriHealth Caritas considers the use of virtual colonoscopy, also known as CT colonography, to be

clinically proven and, therefore, medically necessary when any of the following criteria are met:

A conventional colonoscopy is contraindicated due to presence of lower gastrointestinal

bleeding, colonic stenosis, colonic obstructions, diverticulosis, or diverticulitis.

The patient had complications with a prior colonoscopy.

The patient is taking anti-coagulation medicine, or is otherwise at risk for a bleeding

disorder.

The patient has an elevated risk from sedation during a colonoscopy, from conditions such

as Chronic Obstructive Pulmonary Disease, hypotension from sedation, a recent acute

myocardial infarction, recent colonic surgery, or a previous adverse reaction to anesthesia.

The patient has obstructive colorectal cancer.

Policy contains:

Colonoscopy.

Colorectal cancer.

CT colonography.

Virtual colonoscopy.

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If any of the above criteria is met, CT colonography can be performed every five years from age 50 to 75

for patients not at risk, and starting at age 40 or 10 years before the diagnosis of the youngest affected

relative (whichever is younger) for patients with documented risk factors including relatives with

colorectal cancer under age 60 and genetic diagnosis of hereditary nonpolyposis colorectal cancer (Rex,

2017; Levin, 2008).

CT colonography is considered investigational or experimental, for patients with inflammatory bowel

disease, including Crohn’s, ulcerative colitis, or diverticulitis.

Limitations:

No other indications for virtual colonoscopy are indicated.

Alternative covered services:

Conventional colonoscopy.

Double contrast barium enema.

Fecal immunochemical test.

Fecal occult blood test.

Flexible sigmoidoscopy.

Background

Colonoscopy has long been the most recommended procedure for colorectal cancer screening. Along

with the ability to detect malignancies, colonoscopy can detect pre-cancerous polyps, which can often

be removed during the same procedure. Greater use of the test and its ability to detect and remove

polyps before they become cancerous constitute a major factor in the 47 and 48 percent declines in age-

adjusted U.S. colorectal cancer incidence and mortality from 1985 to 2015 (Noone, 2018).

Colonoscopy is recommended for men and women every 10 years beginning at age 50 for persons not at

risk of colorectal cancer. Persons with a documented risk factor can be screened earlier than age 50.

Colonoscopy is not recommended for persons age 76-85 in the absence of a consideration that supports

screening; and is not recommended for persons over age 85 under any circumstances (U.S. Preventive

Services Task Force, 2015).

The recommendation to perform a colonoscopy is based on the observation that polyps often take 10-

15 years to develop into cancer. However, in 2012, 35 percent of American adults were not up to date

with colon cancer screening (Centers for Disease Control, 2013). Alternative means of cancer screening

to colonoscopy include flexible sigmoidoscopy, double-contrast barium enema, and virtual colonoscopy

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– also known as CT colonography – every five years, stool DNA test - every three years, and annual Fecal

Occult Blood test and fecal immunochemical test (American Cancer Society, 2016).

CT colonography has several advantages over colonoscopy. It is more comfortable for the patient, does

not require sedation (so there is no anesthetic risk like in colonoscopy), and does not disqualify any

patients for certain medical reasons, as colonoscopy sometimes does. CT colonography also requires

less time to complete and return to normal activities than colonoscopy, it carries no risk of surgical

complications (4 - 8 per 10,000 colonoscopy patients, respectively, experience perforations and major

bleeds (Lin, 2016)) and lacks the patient unwillingness factor that some have with colonoscopy.

The major disadvantage of CT colonography compared to colonoscopy is its inability to detect as many

small polyps, and thus CT colonography should be performed every five years, as opposed to every ten

for colonoscopy. Providers of CT colonography are unable to take tissue samples or remove polyps

simultaneously as they can with colonoscopy CT colonography also exposes the patient to radiation

from computerized tomography, although radiation-free medical resonance can be used instead of a CT

scan.

While a dry, clean colon is needed to maximize CT colonography effectiveness, there is no consensus for

optimal bowel preparation. Some CT colonography procedures are performed using minimum-laxative

preparation that employs a fecal tagging technique, such as barium or an iodinated contrast agent

(Nagata, 2009).

Searches

AmeriHealth Caritas searched PubMed and the databases of:

UK National Health Services Centre for Reviews and Dissemination.

Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other

evidence-based practice centers.

The Centers for Medicare & Medicaid Services.

We conducted searches on August 14, 2018. Search terms were: “virtual colonoscopy” and “CT

colonography.”

We included:

Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and

greater precision of effect estimation than in smaller primary studies. Systematic reviews use

predetermined transparent methods to minimize bias, effectively treating the review as a

scientific endeavor, and are thus rated highest in evidence-grading hierarchies.

Guidelines based on systematic reviews.

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Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost

studies), reporting both costs and outcomes — sometimes referred to as efficiency studies —

which also rank near the top of evidence hierarchies.

Findings

The 2008 guideline jointly issued by the American Cancer Society, the US Multi Society Task Force on

Colorectal Cancer, and the American College of Radiology on detecting colorectal cancer and

adenomatous polyps supported use of CT colonography. However, since CT colonography does not

always detect small polyps, the panel recommended CT colonography every five years, versus 10 years

for conventional colonoscopy (Levin, 2008). The most recent guideline, from the U.S. Multi Society Task

Force on Colorectal Cancer, upheld the recommendation for CT colonography every five years (Rex,

2017).

The latest guidelines from the American Cancer Society concurred with the five-year recommendation

(Wolf, 2018). The U.S. Preventive Services Task Force agreed that while CT colonography is effective for

detecting colorectal cancer and large polyps, no such statement can be made for smaller polyps

(Whitlock, 2008).

The National Comprehensive Cancer Network declared that CT colonography is useful for the detection

of large polyps. It recommends the test every five years, and recommends rescreening in three years (or

colonoscopy) if 1 - 2 polyps of 6 - 9 mm are detected (Provenzale, 2018). The American College of

Radiology 2014 Practice Parameter for the Performance of Computed Tomography (CT) Colonography in

Adults lists particular indications when CT colonography should be performed (American College of

Radiology, 2014).

However, a 2016 U.S. Preventive Services Task Force recommendation statement, while recommending

CT colonography every five years as one option for colorectal cancer screening, also questioned the

efficacy of this procedure as extra colonic findings are identified in 40 to 70 percent of screening exams,

of which only three percent require treatment (U.S. Preventive Services Task Force, 2016).

The U.S. Centers for Medicare and Medicaid Services made a decision in 2009 not to expand Medicare

coverage to include CT colonography as a screening mechanism for colorectal cancer. The Centers,

which provides Medicare coverage for colonoscopy every 10 years (every two years for high-risk

individuals); Fecal Occult Blood test every year; and flexible sigmoidoscopy and barium enema every

four years, declared there was a lack of evidence to support efficacy of CT colonography. During a 30 day

comment period just prior to the decision, 16 comments supported the decision not to expand

Medicare coverage, compared to 337 that opposed it, including numerous medical specialty societies

(Center for Medicare and Medicaid Services, 2009).

A study of 2112 asymptomatic subjects who underwent colonoscopy and colonography on the same day

found that 90 percent of polyps at least 10 mm in diameter detected by colonoscopy were also detected

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by colonography, while 65 percent of polyps 6 mm in diameter were detected by both tests (Johnson,

2008). These results helped serve as a basis for the American College of Radiology recommendation that

individuals with one or more polyps at least 10 mm in diameter (or three or more polyps at least 6 mm)

should be referred for colonoscopy (American College of Radiology, 2014). In Europe, the standard for

referring patients for endoscopic polypectomy is at least one polyp at least 6 mm detected at CT

colonography (Laghi, 2015). There is an absence of consensus governing removal of any polyp less than

6 mm (Levin, 2008).

A systematic review/meta-analysis compared prevalence of colorectal cancer between those who did

and did not undergo virtual colonoscopy. Studies of those who did undergo the test (21 studies,

n=1673) had a higher prevalence than those in studies of those who did not undergo the test (27

studies, n=111,873), a difference of 5.7 versus 3.9 percent, significant at P = .004 (Flor, 2018).

An early meta-analysis of 24 studies and 2610 patients found that CT colonography detected 96 percent

of cancers, 93 percent of large polyps, and 86 percent of large and medium polyps combined, but much

lower rates for small polyps (Halligan, 2005). The 96 percent detection rate was also documented in a

more recent meta-analysis of 49 studies, with the figure rising to 100 percent when cathartic and

tagging agents were combined in bowel preparation (Pickhardt, 2011). No differences in sensitivity of

polyp detection were observed between 2-dimensional and 3-dimensional CT colonography (Rosman,

2007).

Another early meta-analysis (33 studies, n=6393) of CT colonography found rising sensitivity as polyp

size increased (48 percent <6 mm, 70 percent 6-9 mm, 85 percent >9 mm), but a consistent specificity,

i.e. 92, 93, and 97 percent (Mulhall, 2005). The most recent U.S. Preventive Services Task Force review

found that CT colonography detected adenomas greater than 6 mm at the same rate (sensitivity 73 to

98 percent) as those undergoing colonoscopy, based on seven studies (Lin, 2016). The most recent

systematic review of 19 articles (n=11,540) determined sensitivity and specificity of polyps at least 6 mm

to be 80 and 89 percent; the same figures were 87 and 97 percent for polyps at least 10 mm (Yu, 2017).

A systematic review/meta-analysis of colorectal cancer prevalence three years after CT colonography

included 12 studies from 2002-2015 (n=19,867). CT colonography detected 643 colorectal cancers, while

29 additional (post-imaging) colorectal cancers were detected, which equaled 1.61 post-imaging

colorectal cancers per 1000 CT colonographies (Obaro, 2018).

Colonoscopy is uniformly regarded as the most efficacious means of screening for polyps and cancers,

although it still does not detect all of these growths. One study of 1731 polyps in persons undergoing CT

colonography and later colonoscopy found 66 of these were false positives for CT colonography, and 78

were potential false positives for colonoscopy, an insignificant difference (Pooler, 2016).

CT colonography reliability was also tested by comparing initial and follow up tests (4.5 to 10.7 years

difference) for 1429 patients who were initially negative for polyps at least 6 mm. The second test found

reduced proportions of patients with lesions over 6 mm (14.3 to 12.1 percent), and large polyps (5.2 to

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3.8 percent). Study authors concluded that CT colonography every 5 - 10 years is an acceptable means of

colorectal cancer screening (Pickhardt, 2017).

The ability of CT colonography to detect tumors outside the bowel wall has been documented. A recent

review of 13 studies showed this type of colon carcinoma was detected by CT colonography in 90

percent of T3-T4 tumors. Sensitivity of detection of tumor invasion depth >5 mm (77 percent) and nodal

involvement (71 percent) were both relatively high (Nerad, 2016).

The resulting diagnostic testing and (sometimes) treatment of extracolonic findings should be

considered in any assessment of effectiveness (Bibbins-Domingo K, 2016). A systematic review/meta-

analysis of 44 studies (n=49,676) patients from 1994 to 2017) identified 4.9 percent of CT

colonographies with potentially important extracolonic findings, which declined by nine percent per

year since 2006 (Pickhardt, 2018).

CT colonography has also been studied as a test in patients who have a positive Fecal Occult Blood test ,

often conducted when colonoscopy is incomplete or infeasible. A meta-analysis of five studies consisting

of 622 Fecal Occult Blood test-positive subjects found an 88.8 percent sensitivity rate for CT

colonography in detecting colorectal cancer or adenomas >6 mm (Plumb, 2014).

CT colonography detection of polyps using minimum-laxative bowel preparation has been compared to

full-laxative preparation. One study compared 50 patients given minimal preparation (45 mL sodium

diatrizoate in the three days before, plus 10 mL of sodium picosulfate the night before CT colonography)

with a similar number of patients given complete laxative preparation. The detection of polyps at least 6

mm was 88 percent in the minimum preparation group, versus 97 percent for the maximum group; but

specificity was relatively low, at 68 versus 92 percent for the maximum group (Nagata, 2009).

Research has also been conducted on the ability of magnetic resonance to detect polyps during virtual

colonoscopy. One systematic review of 13 studies (n=1285) compared magnetic resonance with

conventional colonoscopy; magnetic resonance detected 100 percent of cancers and 88 percent of

polyps over 10 mm, with 99 percent specificity (Zitja, 2010). In a group of 315 patients with no bowel

cleansing given magnetic resonance colonography, 83 percent of polyps over 5 mm were detected,

compared to just 10 percent of lesions under 5 mm (Kuehle, 2007).

A cost-effectiveness analysis concluded that CT colonography conducted every five years was equally

effective to sigmoidoscopy every five years plus annual Fecal Occult Blood test, but less effective than

colonoscopy performed every ten years, assuming a $488 cost for CT colonography and a $500 cost for

colonoscopy, which is the CMS payment for the procedure without polypectomy (Zauber, 2009). A

meta-analysis of 16 studies found CT colonography to be more cost effective than no screening, flexible

sigmoidoscopy, and Fecal Occult Blood test, while comparisons between CT colonography and

colonoscopy were mixed (Hanly, 2012). Medicare costs are 29 percent less for CT colonography than for

colonoscopy (Pyenson, 2015). A systematic review of seven studies (n=765) found that CT colonography

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would save 20.8 million euros a year in the United Kingdom if it was used as a single substitute for

colonoscopy (Porte, 2017).

Policy updates:

A total of three guidelines/other and three peer-reviewed references were added to, and three

guidelines/other removed from this policy in August 2018.

Summary of clinical evidence:

Citation Content, Methods, Recommendations

Pickhardt (2017) Repeat CT colonography after initial screening fails to detect large polyps

Key points:

Single institution study based on 5640 subjects screened with CT colonography before 2010; no polyps at least 6 mm were detected.

1429 of these subjects returned for repeat CT colonography, a mean of 5.7 years later.

Rate of positive detection of large polyps during repeat CT colonography was 3.8 percent (%), significantly lower than 5.2% during original screening (P <.02).

No differences in detection of advanced neoplasia and colorectal cancer between initial and repeat tests.

More advanced right sided lesions detected during follow up.

Findings uphold 5-10 year cycle for repeat CT colonography testing.

Bibbins-Domingo (2016) U.S. Preventive Services Task Force updated colon cancer screening recommendations

Key points:

CT colonography every five years over age 50 is recommended as one option for screening.

Knowledge of CT colonography effectiveness is limited to studies of test characteristics.

CT colonography can result in unneeded diagnostic/therapeutic services, as extracolonic findings occur in 40-70% of exams, with only 3% requiring treatment.

“Evidence to bound the potential harms of this technology is still lacking, particularly in regard to incidental findings”

Nerad (2016) CT colonography detection of tumors beyond the bowel wall

Key points:

13 studies of CT colonography in patients with colon carcinoma.

90% sensitivity (T3-T4 tumors beyond the bowel wall detected).

77% detection of tumor invasion depth >5 mm.

71% detection of nodal involvement.

Pickhardt (2011) Sensitivity study of CT colonography for colorectal cancer

Key points:

Meta-analysis, 49 studies (n=11,151), 414 colorectal cancers.

CT colonography sensitivity was 96.1% (398 of 414).

No cancers were missed by CT colonography when cathartic and tagging agents were combined in the bowel preparation.

Halligan (2005) Sensitivity study of CT colonography for colorectal cancer and polyps

Key points:

Meta-analysis (24 studies, 2610 subjects).

96% of 150 cancers and 93% of 206 large polyps detected.

Detection of small polyps much lower.

Mulhall (2005)

Key points:

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Citation Content, Methods, Recommendations

Sensitivity and specificity of CT colonography by size of polyp

Meta-analysis (33 studies, 6393 subjects).

CT colonoraphy detected rising proportion of polyps, according to size (48% <6 mm, 70% 6-9 mm, 85% > 9 mm).

Specificity consistent across polyp sizes (92%, 93%, 97%).

References

Professional society guidelines/other:

American Cancer Society. American Cancer Society Guidelines for the Early Detection of Cancer.

http://www.cancer.org/healthy/findcancerearly/cancerscreeningguidelines/american-cancer-society-

guidelines-for-the-early-detection-of-cancer. Last updated May 30, 2018. Accessed August 14, 2018.

American College of Radiology. ACR–SAR–SCBT-MR Practice Parameter for the Performance of

Computed Tomography (CT) Colonography in Adults. Reston VA: American College of Radiology, 2014.

https://www.acr.org/-/media/ACR/Files/Practice-Parameters/ct-colonog.pdf Accessed September 28,

2017.

Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for colorectal cancer: US Preventive Services

Task Force recommendation statement. JAMA. 2016;315(23):2564-2575. Doi: 10.1001/jama.2016.5989.

Centers for Medicare and Medicaid Services. Decision Memo for Screening Computed Tomography

Colonography (CTC) for Colorectal Cancer. May 12, 2009. https://www.cms.gov/medicare-coverage-

database/details/nca-decision-

memo.aspx?NCAId=220&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=

colonography&KeyWordLookUp=Title&KeyWordSearchType=And&from2=viewdecisionmemo.asp&id=2

20&bc=gAAAACAACAAAAA%3d%3d&. Accessed August 14, 2018.

Farraye FA, Adler DG, Chand B, et al. American Society of Gastrointestinal Endoscopy (ASGE) Technology

Committee. Update on CT colonography. Gastrointest Endosc. 2009;69(3 Pt 1):393-398. Doi:

10.1016/j.gie.2008.10.009.

Friedman A, Lance P. American Gastroenterological Association. AGA position statement of computed

tomographic colonography. Gastroenterology. 2007;132(4):1632-1633.

Laghi A, Neri E, Regge D. Editorial on the European Society of Gastrointestingal Endoscopy (ESGE) and

European Society of Gastrointestinal and Abdominal Radiology (ESGAR) guideline on clinical indications

for CT colonography in the colorectal cancer diagnosis. Radiol Med. 2015;120(11):1021-1023. Doi:

10.1007/s11547-015-0537-x.

Levin B, Lieberman DA, McFarland B, et al. Screening and Surveillance for the Early Detection of

Colorectal Cancer and Adenomatous Polyps: A Joint Guideline from the American Cancer Society, the US

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Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin.

2008;58(3):130-160. Doi: 10.3322/CA.2007.0018.

Noone AM, Howlader N, Krapcho M, et al (eds). SEER Cancer Statistics Review, 1975-2015, Bethesda

MD: National Cancer Institute, April 2018.

https://seer.cancer.gov/csr/1975_2015/results_merged/sect_06_colon_rectum.pdf. Accessed August

14, 2018.

Provenzale D, Gupta S, Ahnen DJ, et al. NCCN Guidelines Insights: Colorectal Cancer Screening, Version

1.2018. Fort Washington PA: National Comprehensive Cancer Network, 2018. J Natl Compr Canc Netw

2018;16:939-949. http://www.jnccn.org/content/16/8/939.full Accessed August 14, 2018. Doi:

10.6004/jnccn.2018.0067.

Rex DK, Kahi CJ, Levin B, et al. Guidelines for colonoscopy surveillance after cancer resection: a

consensus update by the American Cancer Society and US Multi-Society Task Force on Colorectal Cancer.

CA Cancer J Clin. 2006;56(3):160-167.

Rex DK, Boland CR, Dominitz JA. Colorectal Cancer Screening: Recommendations for Physicians and

Patients From the U.S. Multi-Society Task Force on Colorectal Cancer. Gastroenterology.

2017;153(1):307-323. Doi: 10.1053/j.gastro.2017.05.013.

U.S. Centers for Disease Control and Prevention. Vital Signs: Colorectal Cancer Screening Test Use –

United States, 2012. Atlanta GA: Morbidity and Mortality Weekly Report, November 8, 2013;62(44):881-

888. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6244a4.htm. Accessed August 14, 2018.

U.S. Preventive Services Task Force. Colorectal Cancer Screening: Recommendation Summary.

https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/colorectal-

cancer-screening. Rockville MD: U.S. Preventive Services Task Force, July 2015. AccessedAugust 14,

2018.

Whitlock EP, Lin JS, Liles E, et al. Screening for Colorectal Cancer: A Targeted, Updated Systematic

Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149:638-658.

Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018

guideline update from the American Cancer Society. CA Cancer J Clin. 2018 May 30. Doi:

10.3322/caac.21457.

Yee J, Kim DH, Rosen MP, et al. ACR Appropriateness Criteria colorectal cancer screening. J Am Coll

Radiol. 2014;11(6):543-551. Doi: 10.1016/j.jacr.2014.02.006.

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Zauber AG, Knudsen AM, Rutter CM, et al. Cost-effectiveness of CT colonography to screen for colorectal

cancer. Report to AHRQ from the Cancer Intervention and Surveillance Modeling Network (CISNET) for

MISCAN, SimCRC, and CRC-SPIN Models. Rockville MD: Agency for Health Research and Quality, January

22, 2009. https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id58TA.pdf.

Accessed August 14, 2018.

Peer-reviewed references:

de Haan MC, van Gelder RE, Graser A, Bipat S, Stoker J. Diagnostic value of CT-colonography as

compared to colonoscopy in an asymptomatic screening population: a meta-analysis. Eur Radiol.

2011;21(8):1747-1763. Doi: 10.1007/s00330-011-2104-8.

Flor N, Zancetta E, Di Leo G, et al. Synchronous colorectal cancer using CT colonography vs. other

means: a systematic review and meta-analysis. Abdom Radiol (NY). 2018 Jun 8. Doi: 10.1007/s00261-

018-1658-1.

Halligan S, Altman DG, Taylor SA, et al. CT colonography in the detection of colorectal polyps and cancer:

systematic review, meta-analysis, and proposed minimum data set for study level reporting. Radiology.

2005;237(3):893-904.

Hanly P, Skally M, Fenlon H, Sharp L. Cost-effectiveness of computed tomography colonography in

colorectal cancer screening: a systematic review. Int J Technol Assess Health Care. 2012;28(4):415-423.

Doi: 10.1017/S0266462312000542.

Johnson CD, Chen MH, Toledano AY, et al. Accuracy of CT colonography for detection of large adenomas

and cancers. N Engl J Med. 2008; 359(12):1207-1217.

Kuehle CA, Langhorst J, Ladd SC, et al. Magnetic resonance colonography without bowel cleansing: a

prospective cross sectional study in a screening population. Gut. 2007;56(8):1079-1085.

Lin JS, Piper MA, Perdue LA, et al. Screening for colorectal cancer: updated evidence report and

systematic review for the US Preventive Services Task Force. JAMA. 2016;315(23):2576-2594. Doi:

10.1001/jama.2016.3332.

Martin-Lopez JE, Beltran-Calvo C, Rodriguez-Lopez R, Molina-Lopez T. Comparison of the accuracy of CT

colonography and colonoscopy in the diagnosis of colorectal cancer. Colorectal Dis. 2014;16(3):O82-89.

Doi: 10.1111/codi.12506.

Mulhall BP, Veerappan GR, Jackson JL. Meta-analysis: computed tomographic colonography. Ann Intern

Med. 2005;142(8):635-650.

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Nagata K, Okawa T, Honma A, Endo S, Kudo SE, Yoshida H. Full-laxative versus minimum-laxative fecal-

tagging CT colonography using 64-detector row CT: prospective blinded comparison of diagnostic

performance, tagging quality, and patient acceptance. Acad Radiol. 2009;16(7):780-789.

Nerad E, Lahaye MJ, Maas M, et al. Diagnostic accuracy of CT for local staging of colon cancer: a

systematic review and meta-analysis. Am J Roentgenol. 2016;207(5):984-995.

Obaro AE, Plumb AA, Fanshawe TR, et al. Post-imaging colorectal cancer or interval cancer rates after

CT colonography: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2018;3(5):326-

336. Doi: 10.1016/S2468-1253(18)30032-3.

Pickhardt PJ, Correale L, Morra L, Regge D, Hassan C. JOURNAL CLUB: Extracolonic findings at CT

colonography: systematic review and meta-analysis. Am J Roentgenol. 2018;211(1):25-39. Doi:

10.2214/AJR.17.19495.

Pickhardt PJ, Pooler BD, Mbah I, Weiss JM, Kim DH. Colorectal findings at repeat CT colonography

screening after initial CT colonography screening negative for polyps larger than 5 mm. Radiology.

2017;282(1):139-148. Doi: 10.1148/radiol.2016160582.

Pickhardt PJ, Hassan C, Halligan S, Marmo R. Colorectal cancer: CT colonography and colonoscopy for

detection – systematic review and meta-analysis. Radiology. 2011;259(2):393-405. Doi:

10.1148/radiol.11101887.

Plumb AA, Halligan S, Pendse DA, Taylor SA, Mallett S. Sensitivity and specificity of CT colonography for

the detection of colonic neoplasia after positive faecal occult blood testing: systematic review and meta-

analysis. Eur Radiol. 2014;24(5):1049-1058. Doi: 10.1007/s00330-014-3106-0.

Pooler BD, Kim DH, Weiss JM, Matkowskyj KA, Pickhardt PJ. Colorectal polyps missed with optical

colonoscopy despite previous detection and localization with CT colonography. Radiology.

2016;278(2):422-429. Doi: 10.1148/radiol.2015150294.

Porte F, Uppara M, Malietzis G, et al. CT colonography for surveillance of patients with colorectal cancer:

Systematic review and meta-analysis of diagnostic efficacy. Eur Radiol. 2017;27(1):51-60.

Pyenson B, Pickhardt PJ, Sawhney TG, Berrios M. Medicare cost of colorectal cancer screening: CT

colonography vs. optical colonoscopy. Abdom Imaging. 2015;40(8):2966-2976. Doi: 10.1007/s00261-

015-0538-1.

Rosman AS, Korsten MA. Meta-analysis comparing CT colonography, air contrast barium enema, and

colonoscopy. Am J Med. 2007;120(3):203-210.e4.

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Whitlock EP, Lin JS, Liles E, Beil TL, Fu R. Screening for colorectal cancer: a targeted, updated systematic

review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149(9):638-658.

Yu HH, Huang HY, Jiang YS, et al. Accuracy of CT colonography for the detection of colorectal neoplasm:

a subgroup Meta-analysis. Zhanghua Liu Xing Bing Xue Za Zhi. 2017;38(6):814-820. Doi:

10.3760/cma.j.issn.0254-6450.2017.06.025.

Zitja FM, Bipat S, Stoker J. Magnetic resonance (MR) colonography in the detection of colorectal lesions:

a systematic review of prospective studies. Eur Radiol. 2010;20(5):1031-1046. Doi: 10.1007/s00330-009-

1663-4.

Centers for Medicare & Medicaid Services National Coverage Determinations:

No National Coverage Determinations identified as of the writing of this policy.

Local Coverage Determinations:

L33452 Virtual Colonoscopy (CT Colonography). Palmetto GBA. Effective date May 3, 2018.. Accessed

August 14, 2018.

L33562 Computed Tomographic (CT) Colonography for Diagnostic Uses. National Government Services

Inc Effective date October 1, 2017.Accessed August 14, 2018.

L34055 Virtual Colonoscopy (CT Colonography). CGS Administrators LLC. Effective date October 1, 2017.

Accessed August 14, 2018.

Commonly submitted codes

Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is

not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and

bill accordingly.

CPT Code Description

74261 Computed tomographic (CT) colonography, diagnostic, including imaging postprocessing; without contrast material

74262 Computed tomographic (CT) colonography, diagnostic, including imaging postprocessing; with contrast material(s) including non-contrast images, if performed

74263 Computed tomographic (CT) colonography, screening, including image postprocessing

ICD-10 Code Description

C18.0-C18.9 Malignant neoplasm of colon

C19 Malignant neoplasm of rectosigmoid junction

D68.61-D68.9 Coagulation defects

K56.600-K56.699 Intestinal obstruction

13

ICD-10 Code Description

K57.00-K57.93 Diverticular disease of intestine

T41.205A-T41.205S Adverse effect of unspecified general anesthetics

Z79.01 Long term (current) use of anticoagulants

Z92.89 Personal history of complication of medical care

HCPCS Level II Code

Description

N/A