Clinical UM Guideline


Subject:Colonoscopy
Guideline #:  CG-SURG-01Current Effective Date:  07/09/2013
Status:RevisedLast Review Date:  05/09/2013

Description

Colonoscopy describes the direct visual inspection of the entire colon and rectum.  Additionally, biopsy or excision of polyps or other abnormalities are possible during the colonoscopy procedure. 

Colonoscopy must be distinguished from CT colonography, an imaging procedure that provides indirect visualization of the colon and rectum using CT scans.  This procedure is considered separately in RAD.00029.

Clinical Indications

NOTE: The parenthetical numbers in the Clinical Indications section refer to the source documents cited in the References Section below. 

Screening Colonoscopy 

Medically Necessary: 

Screening Colonoscopy in Average Risk (i.e., those without specific risk factors or family history of colorectal cancer or adenomas and asymptomatic populations).

Note: The higher incidence and younger age at presentation of colorectal cancer in African Americans warrant initiation of colorectal cancer screening at age 45 years rather than 50 years. (1)

 Screening Colonoscopy in Higher Risk (or Increased Risk) Populations            

The timing of the subsequent colonoscopy should depend on the pathology and the number of adenomas detected at the "follow-up colonoscopy.  "For example, if the first "follow-up colonoscopy" is normal or only 1 or 2 small (less than 1cm) tubular adenomas are found, then the next colonoscopy can be in 5 years. (3)

Note: While the above is applicable to individuals with FAP and their families, there are variants of this syndrome, attenuated adenomatous polyposis coli (AAPC) (also referred to as attenuated FAP) and MYH-associated polyposis.  The genetic mutations leading to these variants differ from that in the typical FAP individual.  These variants are associated with a variable number of adenomas (usually 20 to 100), a tendency toward right sided lesions, and an age of onset of colorectal cancer that is approximately 10 years later than for others with FAP. As with FAP, genetic counseling for these individuals and early and regular screening is warranted.  It is recommended that this screening begin in the late teens or early 20s, depending on the age of polyp expression in the family. (12)

Not Medically Necessary:

Other indications for screening colonoscopy, not listed above, are considered not medically necessary.

Diagnostic Colonoscopy 

Medically Necessary: 

Diagnostic Colonoscopy is indicated for the evaluation of any of the following:

Not Medically Necessary: 

Other indications for diagnostic colonoscopy, not listed above are considered not medically necessary, including but not limited to the following:

Therapeutic Colonoscopy:

Medically Necessary:

Therapeutic Colonoscopy is generally indicated for any of the following:

Not Medically Necessary:

Other indications for therapeutic colonoscopy, not listed above are considered not medically necessary.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.   Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
45378Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)
45379Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body
45380Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple
45381Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance
45382Colonoscopy, flexible, proximal to splenic flexure: with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
45383Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45384Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45385Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyps(s), or other lesion(s) by snare technique
45386Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures
45387Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation)
  
HCPCS 
G0105Colorectal cancer screening; colonoscopy on individual at high risk
G0121Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
  
ICD-9 Diagnosis 
 All diagnoses
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
 All diagnoses
   
Discussion/General Information

Screening, surveillance and diagnostic indications for colonoscopy are based on guidelines from a variety of specialty societies and government organizations.  The source for each of the indications listed above is indicated by the referenced citation.

References
  1. Agrawal S, Bhupinderjit A, Bhutani MS, et al. Colorectal cancer in African Americans. Am J Gastroenterol. 2005; 10(3)0:515-523. 
  2. American Cancer Society recommendations for colorectal cancer early detection. Revised 01/24/2013.  Available at: http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/ColonandRectumCancerEarlyDetection/colorectal-cancer-early-detection-acs-recommendations.  Accessed on April 9, 2013.
  3. American Gastroenterological Association. Colorectal Cancer Screening and Surveillance: Clinical Guidelines and Rationale.  Update Based on New Evidence. Gastroenterology, February 2003.Vol 124. 
  4. American Society for Gastrointestinal Endoscopy (ASGE). Appropriate use of gastrointestinal endoscopy. 2000. Available at: http://www.askasge.org/uploadedFiles/Publications_and_Products/Practice_Guidelines/2000_appropriate.pdf. Accessed on April 9, 2013.
  5. American Society for Gastrointestinal Endoscopy. ASGE Guideline. Colorectal Cancer Screening and Surveillance (2006). Gastrointest Endosc. 2006; 63(4):546-557.
  6. Centers for Medicare and Medicaid Services. National Coverage Determination for Colorectal Cancer Screening Tests. NCD #210.3. Effective January 1, 2004. Available at: http://www.cms.hhs.gov. Accessed on April 9, 2013.
  7. Giardiello FM, Brensinger D, Petersen GM. American Gastroenterological Association (AGA) technical review on hereditary colorectal cancer and genetic testing. Gastroenterology 2001; 121(1):198-213
  8. Levin B, Lieberman DA, McFarland B, et al. Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin. 2008; 58(3):130-160. 
  9. Rex DK, Johnson DA, Anderson JC, et al.  American College of Gastroenterology guidelines for colorectal cancer screening, 2008. 
  10. U.S. Preventive Services Task Force.  Screening for colorectal cancer.  US Preventive Service Task Force recommendation statement.  Ann Intern Med 2008; 149(9):627-637.  Available at:  http://www.guideline.gov/summary/summary.aspx?doc_id=13133&nbr=006722&string=colorectal+AND+cancer+AND+screening  Accessed on April 9, 2013.
  11. Worthington DV.  American Academy of Family Physicians (AAFP) position paper:  Colonoscopy: procedural skills. Am Fam Physician. 2000; 62(5):1177-1182. Available at: http://www.aafp.org/afp/20000901/aafp.htmlAccessed on April 9, 2013.
  12. National Comprehensive Cancer Network® (NCCN) Clinical Practice Guidelines in Oncology @ 2011. National Comprehensive Cancer Network, Inc. Colorectal Cancer Screening (V2.2012). Revised April 27, 2012. For additional information: http://www.nccn.org/.  Accessed on April 9, 2013.
  13. Farraye FA, Odze RD, Eaden J, et al. American Gastroenterological Association (AGA). AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease.  Gastroenterology. 2010; 138(2):738-745.  Available at:  http://www.gastrojournal.org/article/S0016-5085(09)02202-1/fulltext. . Accessed on April 9, 2013.
Index

Colonoscopy
Colorectal Cancer Screening

History
StatusDateAction 
Revised05/09/2013Medical Policy & Technology Assessment (MPTAC) review. Expanded medically necessary criteria to address: (1) Individuals with personal history of hyperplastic, left-sided, non-SSP; (2) Individuals with a family history of CRC or adenomas and (3) serrated polyposis syndrome (SPS). Inserted or deleted "and" or "or" in the criteria as needed to provide clarity. Updated review date and References.
Revised05/10/2012MPTAC review. Expanded medically necessary criteria for individuals with FAP to include annual colonoscopy beginning at ages 10-12 years.  Updated review date, References and History sections.
Reviewed05/19/2011MPTAC review.  Updated review date, References and History sections.
Revised05/13/2010MPTAC review.  Criteria updated based on the National Comprehensive Cancer Network. Guidelines on Colorectal Cancer Screening V1.2010 and the 2010 American Gastroenterological Association (AGA) Position Paper on Screening Patients with Inflammatory Bowel Disease (IBD) for Colorectal Cancer. Updated review date, References and History sections.
Reinstated02/25/2010MPTAC review.  Reinstated document which was archived on November 19, 2009. Grammatical and typographical corrections made to clinical indications.
Historic11/19/2009Not to be used for dates of service on or after 11/19/2009.
Reviewed05/21/2009MPTAC review. Added references to the following guidelines and noted where they were applicable in the patient selection criteria: (1) American College of Gastroenterology guidelines for colorectal cancer screening (2008); (2) National Comprehensive Cancer Network.  Colorectal Cancer Screening V1.2009; (3) US Preventive Services Task Force.  Screening for colorectal cancer (2008).  Also, in the patient selection criteria for FAP, added information to the "Note" to clarify that MYH-associated is the same as attenuated FAP. Minor formatting changes. No substantive change to patient selection criteria. Updated review date, description, discussion/general information and history sections.
Revised05/15/2008MPTAC review.  Revised the patient selection criteria to reflect the recommendations made in the Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Updated review date, rationale and references sections.
Reviewed05/17/2007MPTAC review. Updated references, coding, and review date.
Revised06/08/2006MPTAC revision.  For clinical indication, Family History of Colorectal Cancer or Adenoma, criteria updated to two or more first-degree relatives. 
Reviewed03/23/2006MPTAC annual review. References updated.
 11/17/2005Added reference for Centers for Medicare & Medicaid Services (CMS) -National Coverage Determination (NCD).
Revised04/28/2005MPTAC review.  Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem BCBS

West Region

Utilization Management Policy

08/12/2004

UMR.003Colorectal Cancer Screening
WellPoint Health Networks, Inc.

12/02/2004

Clinical GuidelineColonoscopy