Subject:
Colorectal Cancer Screening
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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According to UpToDate, Colorectal cancer (CRC) is a common and lethal cancer worldwide. CRC is one of the leading causes of cancer death in the United States, accounting for 8 to 9 percent of cancer deaths overall. Approximately one in three people who develop CRC die of this disease within five years. The lifetime incidence of CRC in the United States is 4.4 percent for men and 4.1 percent for women. CRC is infrequent before age 40; the incidence rises progressively to 3.7/1000 per year by age 80, with 90 percent of cases occurring after age 50.
Regulatory Status
On August 12, 2014, Cologuard™ (Exact Sciences) was approved by the U.S. Food and Drug Administration (FDA) through the premarket approval process as an automated fecal DNA testing product (P130017). Cologuard™ is intended for the qualitative detection of colorectal neoplasia associated DNA markers and of occult hemoglobin in human stool. A positive result may indicate the presence of CRC or advanced adenoma and should be followed by diagnostic colonoscopy. Cologuard™ is indicated to screen adults of either sex, 50 years or older, who are at average risk for CRC. Cologuard™ is not a replacement for diagnostic colonoscopy or surveillance colonoscopy in high-risk individuals.
Over the past several years, different stool DNA tests have been evaluated in studies, and some have been marketed. One previously marketed test, PreGen-Plus™ (LabCorp), tests for 21 different variants in the p53, adenomatous polyposis coli, and KRAS genes; the BAT-26 microsatellite instability marker; and incorporates the DNA Integrity Assay (DIA®). PreGen-Plus™ has not been cleared by FDA. In January 2006, FDA informed LabCorp that PreGen-Plus™ may be subject to FDA regulation as a medical device. As a consequence, and as a result of studies showing better performance of other tests, this test is no longer offered. Another previously marketed test is called ColoSure™ (OncoMethylome Sciences; now MDxHealth), which detects aberrant methylation of the vimentin (hV) gene. This test was offered as a laboratory-developed test and is not subject to FDA regulation.
Related Policies
- Adult Abdomen Imaging Policy (Policy #148 in the Radiology Section)
Policy:
[INFORMATIONAL NOTE: The following Federal and NJ State mandates are related to colorectal cancer screening:
Health Care Reform (HCR):
HCR specifies that a group health plan (refers to insured and self-insured groups) and a health insurance issuer offering group or individual health insurance coverage provide benefits for certain preventive care services as recommended by the US Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the Health Resources and Services Administration. and prohibit cost-sharing for such requirements. The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years. The risks and benefits of different screening methods vary. The decision to screen for colorectal cancer in adults ages 75 to 85 years should be an individual one, taking into account the patient’s overall health and prior screening history.
New Jersey Colorectal Cancer Screening Mandate:
The New Jersey Colorectal Cancer Screening mandate (P.L. 2001, c.295) requires that benefits under affected contracts must be provided for colorectal cancer screening at regular intervals for persons age 50 and over, and for persons of any age who are considered to be at high risk for colorectal cancer. The method and frequency shall be in accordance with most recent published guidelines of the American Cancer Society (ACS) and as determined to be medically necessary by the covered person's doctor, in consultation with the covered person.
Furthermore, the New Jersey Colorectal Cancer Screening mandate specifies that a person with a "high risk for colorectal cancer" is a person who has:
- a family history of (a) familial adenomatous polyposis, or (b) hereditary non-polyposis colon cancer, or (c) breast, ovarian, endometrial, or colon cancer or polyps; or
- chronic inflammatory bowel disease; or
- a background, ethnicity or lifestyle that the doctor believes puts the person at elevated risk for the disease.
The ACS recommends regular colorectal cancer screening starting at age 45 years in individuals with average-risk of colorectal cancer. The recommendation to begin screening at age 45 years is a 'qualified recommendation'. The recommendation for regular screening in adults aged 50 years and older is a 'strong' recommendation. Other 'qualified' recommendations include: (a) average-risk adults in good health with a life expectancy of greater than 10 years continue colorectal cancer screening through age of 75 years; (b) clinicians individualize colorectal cancer screening decisions for individuals ages 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and (c) clinicians discourage individuals over age 85 years from continuing colorectal cancer screening. Several test options are available for colorectal cancer screening. There are some differences between these tests to consider. If a person chooses to be screened with a test other than colonoscopy, any abnormal test result should be followed up with colonoscopy.
The American Cancer Society does not have screening guidelines specifically for people at increased or high risk of colorectal cancer.
New Jersey Health Wellness Promotion Act:
The New Jersey Health Wellness Promotion Act (P.L.1999, c. 339). The applicable provisions of the Health Wellness Promotion Act require benefits for certain health wellness examinations and counseling incurred through a health promotion program. The covered services and tests include, but not limited to, the following:
- For all persons 40 years of age and older - annual stool examination for presence of blood.
- For all persons 45 years of age or older - left-sided colon examination of 35 to 60 centimeters every five years.
For services provided August 1, 2017 and after, Horizon Blue Cross Blue Shield of New Jersey collaborates with eviCore healthcare to conduct Medical Necessity Determination for certain molecular and genomic testing services for members enrolled in Horizon BCBSNJ fully insured products as well as Administrative Services Only (ASO) accounts that have elected to participate in the Molecular and Genomic Testing Program (“the Program”). Beginning August 1, 2017, the criteria and guidelines included in this policy apply to members enrolled in plans that have NOT elected to participate in the Program.
To access guidelines that apply for services provided August 1, 2017 and after to members enrolled in plans that HAVE elected to participate in the Program, please visit www.evicore.com/healthplan/Horizon_Lab.
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.]
I. For benefit plans subject to one or more of the colorectal cancer screening mandates (i.e., Health Care Reform, New Jersey Colorectal Cancer Screening Mandate, and/or New Jersey Health Wellness Promotion Act), colorectal cancer screening is considered medically necessary based on the following criteria:
A. Members at average risk using any one of the following tests starting at age 45 years:
i. High-Sensitivity Stool-Based Tests
- Fecal Immunochemical Test (FIT) every year
- High-Sensitivity Guaiac-Based Fecal Occult Blood Test (HSgFOBT) every year
- Multi-Target Stool DNA Test (MT-sDNA) or FIT-DNA (e.g., Cologuard) every 3 years
ii. Structural (Visual) Examinations
- Colonoscopy every 10 years
- CT Colonography (CTC) or Virtual Colonoscopy every 5 years
- Flexible Sigmoidoscopy (FSIG) every 5 years
(NOTE: According to the American Cancer Society, as part of the screening process all positive results on non-colonoscopy screening tests should be followed up with timely colonoscopy.)
B. Members at increased or high risk based on any one of the following risk factors:
(NOTE: According to the American Cancer Society (ACS), people at increased or high risk of colorectal cancer might need to start colorectal cancer screening before age 45, be screened more often, and/or get specific tests. The ACS does not have screening guidelines specifically for people at increased or high risk of colorectal cancer.)
- a strong family history of colorectal cancer or certain types of polyps
- a personal history of colorectal cancer or certain types of polyps
- a personal history of inflammatory bowel disease (ulcerative colitis or Crohn's disease)
- a known family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or Lynch syndrome (also known as hereditary non-polyposis colon cancer or HNPCC)
- a personal history of radiation to the abdomen or pelvic area to treat a prior cancer.
In addition, the New Jersey State Mandate on Colorectal Cancer Screening (P.L.2001, c.295) also considers a person at high risk for colorectal cancer if the person has any one of the following risk factors:
- a family history of breast, ovarian or endometrial cancer; or
- a background, ethnicity or lifestyle that the doctor believes puts the person at elevated risk for the disease.
II. For benefit plans NOT subject to one or more of the colorectal cancer screening mandates (i.e., Health Care Reform, New Jersey Colorectal Cancer Screening Mandate, and/or New Jersey Health Wellness Promotion Act), colorectal cancer screening using any one of the tests for members at average risk as listed under Policy Statement I.A is considered medically necessary EXCEPT for multi-target stool DNA (MT-sDNA) test or FIT-DNA (e.g., CologuardTM) which is considered medically necessary every three years based on the following medical necessity criteria:
A. For ages 45 to 75 years
i. Member has not had any of the following USPSTF recommended (A rating) colorectal cancer screening performed during the recommended screening interval:
- Guaiac-based fecal occult blood test (gFOBT) in the past year, or
- Fecal immunochemical test (FIT) in the past year, or
- Multitargeted stool DNA test (FIT-DNA) in the past three years, or
- Colonoscopy in the past ten years, or
- CT colonography in the past five years, or
- Flexible sigmoidoscopy in the past five years, AND
ii. No signs or symptoms of colorectal disease, including lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test, AND
iii. Average risk of developing colorectal cancer defined by the following:
- No personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn's Disease and ulcerative colitis, and
- No family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer.
B. For ages 76 to 85 years:
i. Member has never been screened for colorectal cancer by any screening method, AND
ii. No signs or symptoms of colorectal disease, including lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test, AND
iii. Average risk of developing colorectal cancer defined by the following:
- No personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn's Disease and ulcerative colitis, and
- No family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer, AND
iv. Member is healthy enough to undergo treatment if colorectal cancer is detected, AND
v. Member does not have comorbid conditions that would significantly limit his/her life expectancy.
C. For age 86 years and older:
- Routine screening for colorectal cancer is not recommended and therefore not medically necessary.
Medicare Coverage:
Medicare Advantage differs from the Horizon BCBSNJ Medical Policy.
The Multi-Target Stool DNA Test is covered once every 3 years for asymptomatic Medicare Advantage members age 50-85 years who are at average risk of developing colorectal cancer.
Screening Colonoscopies, Fecal Occult Blood Tests (FOBTs), Flexible Sigmoidoscopies, And Barium Enemas are covered for Medicare Advantage members who are either:
- Aged 50 and older who are at normal risk of developing colorectal cancer or
- At high risk of developing colorectal cancer
For individuals Not Meeting Criteria for High Risk:
- Screening FOBT is covered once every 12 months
- Screening flexible sigmoidoscopy is covered once every 48 months (unless the individual does not meet the criteria for high risk of developing colorectal cancer and the individual has had a screening colonoscopy within the preceding 10 years, in which case a screening flexible sigmoidoscopy may be covered only after at least 119 months have passed following the month that the individual received the screening colonoscopy)
- Screening colonoscopy is covered once every 120 months (10 years), or 48 months (4 years) after a previous sigmoidoscopy
- Screening barium enema (when used instead of a flexible sigmoidoscopy or colonoscopy) is covered once every 48 months
For individuals Meeting Criteria for High Risk:
- Screening FOBT is covered once every 12 months
- Screening flexible sigmoidoscopy is covered once every 48 months
- Screening colonoscopy is covered once every 24 months (unless a screening flexible sigmoidoscopy has been performed and then Medicare may cover a screening colonoscopy only after at least 47 months)
- Screening barium enema (when used instead of a flexible sigmoidoscopy or colonoscopy) is covered once every 24 months
National Coverage Determination (NCD) for Colorectal Cancer Screening Tests (210.3). Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx.
National Coverage Determination (NCD) for Fecal Occult Blood Test (190.34). Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx.
Medicare Learning Network MLN Matters Article ICN MLN006559 October 2019. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html.
Note* High risk for colorectal cancer is defined in the Code of Federal Regulations (CFR) 42 CFR Ch. IV (10–1–16 Edition) as:
An individual at high risk for colorectal cancer means an individual with any of the following:
(i) A close relative (sibling, parent, or child) who has had colorectal cancer
or an adenomatous polyp;
(ii) A family history of familial adenomatous polyposis;
(iii) A family history of hereditary nonpolyposis colorectal cancer;
(iv) A personal history of adenomatous polyps; or
(v) A personal history of colorectal cancer; or
(vi) Inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis.
For additional information, refer to the Code of Federal Regulations (CFR) 42 CFR Ch. IV. Available at: https://www.govinfo.gov/content/pkg/CFR-2016-title42-vol2/pdf/CFR-2016-title42-vol2-sec410-37.pdf
Preventative services
CMS may add coverage of preventive services through the National Coverage Determination (NCD) process if the service meets all of the following criteria:
- Reasonable and necessary for the prevention or early detection of illness or disability
- Recommended with a grade of A or B by the United States Preventive Services Task Force (USPSTF)
- Appropriate for individuals entitled to benefits under Part A or enrolled under Part B of the Medicare Program
Medicaid Coverage:
FIDE-SNP Coverage:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Colorectal Cancer Screening
Flexible Colonoscopy and Other Colorectal Cancer Screening Procedures
Colonoscopy Procedures
Endoscopy (Colonoscopy)
Cologuard
Colosure
References:
1. Imperiale TF, Ransohoff DF, Itzkowitz SH, et al. Multitarget stool DNA testing for colorectal-cancer screening. N Engl J Med. Apr 3 2014;370(14):1287-1297. PMID 24645800
2. Ahlquist DA, Zou H, Domanico M, et al. Next-generation stool DNA test accurately detects colorectal cancer and large adenomas. Gastroenterology. 2012;142(2):248-256. PMID
3. Lidgard GP, Domanico MJ, Bruinsma JJ, et al. Clinical performance of an automated stool DNA assay for detection of colorectal neoplasia. Clin Gastroenterol Hepatol. Oct 2013;11(10):1313-1318. PMID 23639600
4. Blue Cross Blue Shield Association. Technology Evaluation Center. Special Report: Fecal DNA Analysis for Colorectal Cancer Screening. Volume 29, No. 8; December 2014
5. Shah R, Jones E, Vidart V, et al. Biomarkers for early detection of colorectal cancer and polyps: systematic review. Cancer Epidemiol Biomarkers Prev. Sep 2014;23(9):1712-1728. PMID 25004920
6. Imperiale TF, Ransohoff DF, Itzkowitz SH, et al. Fecal DNA versus fecal occult blood for colorectal-cancer screening in an average risk population. N Engl J Med. 2004;351(26):2704-2714. PMID
7. Woolf SH. A smarter strategy? Reflections on fecal DNA screening for colorectal cancer. N Engl J Med. 2004;351(26):2755-2758. PMID
8. Schroy PC, Heeren TC. Patient perceptions of stool-based DNA testing for colorectal cancer screening. Am J Prev Med. 2005;28(2):208-214. PMID
9. Itzkowitz SH, Jandorf L, Brand R, et al. Improved fecal DNA test for colorectal cancer screening. Clin Gastroenterol Hepatol. 2007;5(1):111-117. PMID
10. Itzkowitz S, Brand R, Jandorf L, et al. A simplified, noninvasive stool DNA test for colorectal cancer detection. Am J Gastroenterol. 2008;103(11-Jan):2862-2870. PMID
11. Baek YH, Chang E, Kim YJ, et al. Stool methylation-specific polymerase chain reaction assay for the detection of colorectal neoplasia in Korean patients. Dis Colon Rectum. 2009;52(8):1452-1459. PMID
12. Li M, Chen WD, Papadopoulos N, et al. Sensitive digital quantification of DNA methylation in clinical samples. Nat Biotechnol. 2009;27(9):858-863. PMID
13. Ahlquist DA, Sargent DJ, Loprinzi CL, et al. Stool DNA and occult blood testing for screen detection of colorectal neoplasia. Ann Intern Med. 2008;149(7):441-450. PMID
14. Ahlquist DA, Taylor WR, Mahoney DW, et al. The stool DNA test is more accurate than the plasma septin 9 test in detecting colorectal neoplasia. Clin Gastroenterol Hepatol. 2012;10(3):272-277. PMID
15. 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. PMID
16. Qaseem A, Denberg TD, Hopkins RH, Jr., et al. Screening for colorectal cancer: a guidance statement from the American College of Physicians. Ann Intern Med. Mar 6 2012;156(5):378-386. PMID 22393133
17. Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol. Mar 2009;104(3):739-750. PMID 19240699
18. Whitlock EP, Lin JS, Liles E, et al. Screening for colorectal cancer: a targeted, updated systematic review for the US Preventive Services Task Force. Ann Intern Med. 2008;149(9):638-658. PMID
19. Centers for Medicare and Medicaid Services (CMS). Proposed Decision Memo for Screening for Colorectal Cancer - Stool DNA Testing (CAG-00440N). 2014; http://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=277.
20. Centers for Medicare and Medicaid Services (CMS). Final Decision Memorandum for Colorectal Cancer Screening Using Cologuard - A Multitarget Stool DNA Test (CAG-00440N). October 9, 2014. Available at: http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=277.
21. New Jersey State Mandate (P.L. 2001, c. 295) effective 06/29/2002, which requires health benefits coverage for expenses incurred in conducting colorectal cancer screening at regular intervals for persons age 50 and over, and for persons of any age who are considered to be at high risk for colorectal cancer.
22. American Cancer Society. Guideline for Colorectal Cancer Screening. Last Revised: May 30, 2018. Available at: https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html
23. American Cancer Society. Colorectal Cancer: Early Detection, Diagnosis, and Staging. 2018. Available at: https://www.cancer.org/content/cancer/en/cancer/colon-rectal-cancer/detection-diagnosis-staging.html
24. Provenzale D, Jasperson K, Ahnen DJ, et al. Colorectal Cancer Screening, Version 1.2015. J Natl Compr Canc Netw. Aug 2015;13(8):959-968. PMID 26285241.
25. SEER Cancer Statistics Factsheets: Colon and Rectum Cancer. National Cancer Institute. Bethesda, MD. Available at: http://seer.cancer.gov/statfacts/html/colorect.html.
26. U.S. Preventive Services Task Force. Final Recommendation Statement: Colorectal Cancer: Screening. June 2016. Available at https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/colorectal-cancer-screening2
27. Centers for Disease Control and Prevention. Colorectal Cancer. Available at: http://www.cdc.gov/cancer/colorectal/index.htm.
28. Cologuard website. Available at: http://www.cologuardtest.com.
29. Imperiale TF, Ransohoff DF, Itzkowitz SH, et al. Multitarget stool DNA testing for colorectal-cancer screening. N Engl J Med. 2014 Apr 3;370(14):1287-97. doi: 10.1056/NEJMoa1311194. Epub 2014 Mar 19.
30. National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology. Colorectal Cancer Screening. V.1.2018. Available at: https://www.nccn.org/professionals/physician_gls/pdf/colorectal_screening.pdf.
31. FDA. Summary of Safety and Effectiveness Data (SSED). Stool DNA-Based Colorectal Cancer Screening Test: Cologuard. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf13/P130017B.pdf
32. ClinicalTrials.gov. Available at: https://clinicaltrials.gov/ct2/show/NCT02419716.
33. ClinicalTrials.gov. Available at: https://clinicaltrials.gov/ct2/show/NCT02715141.
34. Doubeni C. Screening for colorectal cancer: Strategies in patients at average risk. In: UpToDate, Lamont T, Elmore JG, Melin JA (Eds), UpToDate, Waltham, MA. (Accessed on June 6, 2019.)
35. Ramsey SD, Grady WM. Screening for colorectal cancer in patients with a family history of colorectal cancer or advanced polyp. In: UpToDate, Lamont T, Elmore JG, Melin JA (Eds), UpToDate, Waltham, MA. (Accessed on June 6, 2019.)
36. Doubeni C. Tests for screening for colorectal cancer: Stool tests, radiologic imaging and endoscopy. In: UpToDate, Lamont, JT, Elmore JG, Melin JA (Eds), UpToDate, Waltham, MA. (Accessed on June 6, 2019.)
37. Lindor NM, Win AK. Lynch syndrome (hereditary nonpolyposis colorectal cancer): Screening and management. In: UpToDate, Lamont JT, Goff B, Grover S (Eds), UpToDate, Waltham, MA. (Accessed on June 6, 2019.)
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
45378
45380
45381
45384
45385
45330
45331
74263
74270
74280
81528
82270
82274
HCPCS
G0104
G0105
G0106
G0120
G0121
G0328
G0464
S3890
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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