Clinical UM Guideline


Subject:  Colonoscopy
Guideline #:  CG-SURG-01Current Effective Date:  07/07/2015
Status:RevisedLast Review Date:  05/07/2015

Description

This document addresses colonoscopy, an endoscopic procedure which allows 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 CT Colonography (Virtual Colonoscopy) as a Screening or Diagnostic Test for Colorectal Cancer.

Clinical Indications

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

Medically Necessary:

  1. Screening Colonoscopy in Average Risk Populations (i.e., those without specific risk factors or family history of colorectal cancer, sessile serrated polyps (SSPs) or adenomas and asymptomatic populations).
    1. Colonoscopy to detect colorectal cancer and adenomatous polyps is appropriate:
      1. Beginning at age 50 years (2, 3, 7, 8, 14) or age 45 years for African Americans (1, 11), and
      2. Every 10 years thereafter. (2, 3, 7) or
    2. Individuals who have a prior personal history of having hyperplastic, non-sessile serrated polyp (non-SSP) and less than 1 cm removed at colonoscopy should have the first follow up colonoscopy in 10 years. (7, 8, 9) or
    3. For individuals with a prior personal history of having a negative stool based (guaiac-based, immunohistochemical or Cologuard fecal DNA) test, re-screening may be performed with colonoscopy in 1 year. (9)
      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, 11)
  2. Surveillance Colonoscopy in At-Risk Populations
    1. Individuals who have a prior personal history of having a positive stool based (guaiac-based, immunohistochemical or Cologuard fecal DNA) test and the confirmatory colonoscopy was positive for cancer or pre-cancerous polyp, surveillance may be appropriate based on clinical findings. (9)
    2. Colorectal Cancer: For those with a personal history of colorectal cancer that has been resected with curative intent, colonoscopy is appropriate for any of the following:
      1. To rule out synchronous neoplasms; 3 to 6 months after cancer resection, if no unresectable metastases are found during surgery. Alternatively, colonoscopy can be performed intraoperatively, or preoperatively if non-obstructing tumor; (3, 7, 9, 12) or
      2. 1 year after the curative resection if a complete preoperative colonoscopy was performed, or 3-6 months after curative resection if there was no or incomplete preoperative colonoscopy, or 1 year following the colonoscopy that was performed to clear the colon of synchronous disease; (3, 7, 9, 12) or
      3. 2 to 3 years after the "1 year" follow up colonoscopy, if examination was normal. (2, 3, 4, 7, 9, 12)
      4. For this specific group, colonoscopy may be repeated thereafter at 3 to 5 year intervals, based on previous findings. (2, 3, 4, 7, 9, 12)
    3. Adenomatous Polyps or Sessile Serrated Polyps (SSP): Those who have a prior personal history of having one or more adenomatous polyps or SSPs removed at colonoscopy should be managed according to the findings (that is, considering number of polyps and pathology). Colonoscopy may be appropriate in any of the following individuals:
      1. Those with 1 or 2 small (less than 1 cm) tubular adenomas should have the first follow up colonoscopy in 5 years; (2, 3, 7, 8, 9) or
      2. Those with 3 to 10 adenomas or 1 adenoma greater than or equal to 1 cm or any adenoma with villous features or high-grade dysplasia should have colonoscopy 3 years after the initial polypectomy; (2, 3, 7, 8, 9) or
      3. Those with greater than 10 adenomas on a single examination should have colonoscopy less than 3 years after the initial polypectomy based on clinical judgment; (2, 3, 7, 8) or
      4. Those with a malignant adenoma (with invasive cancer), a large sessile adenoma, or an incomplete colonoscopy should have a short interval follow up based on clinical judgment; or
      5. Those with sessile adenomas that are removed piecemeal should have their first follow-up colonoscopy at 2 to 6 months to verify complete removal. (2, 3, 7)
        Note: 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 10 years. (9)
    4. Serrated Polyposis Syndrome (SPS)
      1. For individuals with serrated polyposis syndrome, colonoscopy is appropriate as follows:
        1. Colonoscopy with polypectomy until all polyps greater than or equal to 5 mm are removed; (10) and
        2. Then colonoscopy every 1 to 3 years depending on the number and size of polyps. (10).
    5. Colonic Adenomatous Polyposis of Unknown Etiology. For individuals with a personal history of colonic adenomatous polyposis of unknown etiology(without known APC or biallelic MUTYH mutations), colonoscopy is appropriate as follows:
      1. Individual with a personal history of more than 10 but less than 100 small (less than 1 cm) adenomas which are manageable by colonoscopy and polypectomy should have colonoscopy every 1 to 2 years. Repeat colonoscopy may be at shorter interval if residual polyps present. (10)
    6. Inflammatory Bowel Disease (chronic ulcerative colitis or Crohn's colitis) and related conditions:
      1. For individuals with inflammatory bowel disease, colonoscopy is appropriate as follows:
        1. Surveillance colonoscopy beginning 8-10 years after onset of pancolitis, 12-15 years after onset of left-sided colitis, and repeated every 1-2 years thereafter. (3, 6, 7, 9)
        2. Individuals with primary sclerosing cholangitis (PSC) should begin surveillance colonoscopy at the time of diagnosis and then undergo yearly colonoscopy thereafter. (6)
  3. Screening Colonoscopy in Higher Risk Populations
    1. Family History of Colorectal Cancer or Adenomas: The vast majority of those with increased risk are in this category. Screening colonoscopy would be appropriate for a person with a family history indicating any of the following:
      1. One first degree relative (parent, sibling or child) with colon cancer or adenoma diagnosed before the age of 60; (3, 7, 8, 11) or
      2. Two or more first-degree relatives with colorectal cancer or adenomas at any age: (2, 7, 11)
        1. Colonoscopy beginning at age 40; (2, 3, 7, 9, 11) or
        2. Colonoscopy beginning at an age 10 years younger than the age at diagnosis of the youngest affected relative, whichever comes first. (2, 3, 7, 9, 11)
        3. For this specific group, colonoscopy may be repeated every 3 to 5 years depending on findings. (2, 3, 7, 8, 9, 11,) or
      3. For those with one first degree relative with colorectal cancer diagnosed at an age greater than or equal to 60 years:
        1. Colonoscopy beginning at age 50; (9) or
        2. For this specific group, colonoscopy may be repeated every 5 years, or if positive, repeat per colonoscopy findings. (9) or
      4. For those with one second degree relative (grandparents, aunts or uncles), with colorectal cancer diagnosed at an age less than 50 years:
        1. Colonoscopy beginning at age 50; (9)
        2. For this specific group, colonoscopy may be repeated every 5 years, or if positive, repeat per colonoscopy findings. (9) or
      5. For those with a first-degree relative with advanced adenoma(s):
        1. Colonoscopy beginning at age 50 or at age of affected relative onset, whichever is first. (9)
        2. For this specific group, colonoscopy may be repeated every 5 years, or if positive, repeat per colonoscopy findings. (9)
          Note: Increased numbers of affected first-degree relatives influences risk much more than affected second-degree relatives or third-degree relatives. However, when combined with a positive first-degree family history, a positive second- and third-degree family history can significantly increase risk (9, 13).
    2. Familial adenomatous polyposis (FAP): In this autosomal dominant syndrome, affected persons have a risk of colorectal cancer approaching 100%. The average age of adenoma appearance is 16, and the average age of colon cancer is 39. Most affected individuals develop more than 100 adenomas. Thus early and regular screening is appropriate for any of the following. (3)
      1. For those with a genetic diagnosis of FAP, or who are at risk for this diagnosis but genetic testing has not been done or is not feasible:
        1. Offer genetic counseling, as specific genetic abnormalities can be identified in approximately 80% of affected individuals. This can then be used to screen other family members. (11) and
        2. Annual sigmoidoscopy or colonoscopy beginning at ages 10-12 years: (2, 3, 10)
          1. With an appropriately timed colectomy indicated when polyps develop; (3, 10, 11) or
          2. If no polyps develop, annual sigmoidoscopy to age 40 then every 3-5 years thereafter. (3) or
      2. For the family members of those with FAP who do not have specific genetic evidence or clinical manifestations of the disease:
        1. The older, unscreened relatives of a person newly diagnosed with FAP should have a colonoscopy for the first screening examination; (9) and
        2. Annual screening sigmoidoscopy until age 40 if no polyps develop; (9) and
        3. An appropriately timed colectomy indicated if polyps develop. (6, 9)
          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. (13)
    3. Lynch Syndrome, also known as Hereditary Non-Polyposis Colorectal Cancer (HNPCC): For individuals with a genetic or clinical diagnosis of, or who are at increased risk for Lynch Syndrome, colonoscopy is appropriate as follows:
      1. For individuals who are MLH1, MSH2 and EPCAM mutation carriers:
        1. Every 1 to 2 years beginning at 20 to 25 years old or 2-5 years prior to the earliest colon cancer in a first-degree relative if it is diagnosed before age 25; (10) or
      2. For individuals who are MSH6 and PMS2 mutation carriers:
        1. Every 1 to 2 years beginning at 25-30 years old or 2-5 years prior to the earliest colon cancer in a first-degree relative if it is diagnosed before age 30. (10)
    4. Serrated Polyposis Syndrome (SPS)
      1. For individuals with a family history of serrated polyposis syndrome, the first-degree relative of the individual with serrated polyposis syndrome should have colonoscopy at the earliest of the following:
        1. Age 40; (10) or
        2. Same age as the youngest diagnosis of serrated polyposis if uncomplicated by cancer; (10) or
        3. Ten years earlier than earliest diagnosis in family of colorectal cancer complicating serrated polyposis. (10)
          1. Following baseline exam, repeat colonoscopy every 5 years if no polyps are found; (10) or
          2. If proximal serrated polyps or multiple adenomas are found, consider colonoscopy every 1 to 3 years. (10)
    5. Colonic Adenomatous Polyposis of Unknown Etiology. For individuals with a family history of colonic adenomatous polyposis of unknown etiology(without known APC or biallelic MUTYH mutations), colonoscopy is appropriate as follows:
      1. Individual with a first-degree relative diagnosed with 100 or more adenomas prior to age 40 years should have colonoscopy as follows:
        1. Beginning at age 10 to 15 years; (10) and
        2. Every 1 year until age 24 years; (10) and
        3. Every 2 years from age 24 to 34 years; (10) and
        4. Every 3 years from age 34 to 44 years; (10) and
        5. Every 3 to 5 years thereafter. (10) or
      2. Individual with a first-degree relative diagnosed with more than 10 but less than 100 adenomas should have colonoscopy every 3 to 5 years beginning at the same age as the youngest diagnosis of polyposis in the family, if uncomplicated by cancer or by age 40, whichever is earliest. If multiple polyps found, then colonoscopy every 1-3 years depending on the type, number and size of polyps. (10) or
      3. Individual with a first-degree relative diagnosed with more than 100 adenomas at age 40 or older, should have colonoscopy every 2 to 3 years, starting at age 40 years if uncomplicated by cancer. If multiple polyps found, then colonoscopy every 1-3 years depending on the type, number and size of polyps. (10)

Not Medically Necessary:

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

Diagnostic Colonoscopy

Medically Necessary:

  1. Diagnostic Colonoscopy is indicated for the evaluation of any of the following:
    1. An abnormality on barium enema or other imaging study that is likely to be clinically significant (filling defect, stricture); (4) or
    2. Unexplained gastrointestinal tract bleeding such as: (4)
      1. Hematochezia; (4) or
      2. Melena after an UGI tract source has been excluded; (4) or
      3. Presence of fecal occult blood; (4) or
      4. Unexplained iron deficiency anemia; (4) or
    3. A suspicion of inflammatory bowel disease, which may be manifested by abdominal pain, fever, diarrhea, bloody diarrhea, elevated erythrocyte sedimentation rate, etc.; or
    4. Clinically significant diarrhea of unexplained origin after other appropriate work up; (4) or
    5. A metastatic adenocarcinoma of unknown primary origin when colon cancer is suspected; or
    6. Intraoperative identification of a lesion not apparent at surgery (e.g., polypectomy site, location of a bleeding site). (4)

Not Medically Necessary:

  1. Other indications for diagnostic colonoscopy, not listed above are considered not medically necessary, including but not limited to the following:
    1. Chronic, stable irritable bowel syndrome; (4) and
    2. Chronic abdominal pain; (4) and
    3. Acute diarrhea; (4) and
    4. Routine follow-up of inflammatory bowel disease except for cancer surveillance in chronic ulcerative colitis and Crohn's colitis; (4) and
    5. Upper GI tract bleeding or melena with a demonstrated upper GI source. (4)

Therapeutic Colonoscopy

Medically Necessary:

  1. Therapeutic Colonoscopy is generally indicated for any of the following:
    1. Removal of foreign body; (4) or
    2. Balloon dilation of stenotic lesions (e.g., anastomotic strictures); (4) or
    3. Excision of colonic polyps; (4) or
    4. Decompression of sigmoid volvulus or an acute nontoxic megacolon; (4) or
    5. Palliative treatment of stenosing or bleeding neoplasms (e.g., laser, electrocoagulation, stenting); (4) or
    6. Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasia, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy); (4) or
    7. Pre-operative "marking" for localization of a lesion. (4)

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. 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; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
45379Colonoscopy, flexible; with removal of foreign body(s)
45380Colonoscopy, flexible; with biopsy, single or multiple
45381Colonoscopy, flexible; with directed submucosal injection(s), any substance
45382Colonoscopy, flexible; with control of bleeding, any method
45384Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45385Colonoscopy, flexible; with removal of tumor(s), polyps(s), or other lesion(s) by snare technique
45386Colonoscopy, flexible; with transendoscopic balloon dilation
45388Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
45389Colonoscopy, flexible; with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed)
  
HCPCS 
G0105Colorectal cancer screening; colonoscopy on individual at high risk
G0121Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G6024Colonoscopy, 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
G6025Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation)
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 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.

Generally speaking, screening refers to an effort or program which is used to detect a condition in an asymptomatic individual so that early detection and treatment can be provided for those who test positive for the condition. Diagnostic testing is typically done to confirm or rule out a condition in an individual who is symptomatic or who, for some other reason, is believed to have a specific condition. Surveillance testing is generally carried out to monitor for the recurrence of a disease in an individual who was previously treated for and believed to be free of the disease.

References
  1. Agrawal S, Bhupinderjit A, Bhutani MS, et al. Colorectal cancer in African Americans. Am J Gastroenterol. 2005; 100 (3):515-523.
  2. American Cancer Society recommendations for colorectal cancer early detection. Revised 02/05/2015. Available at: http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/ColonandRectumCancerEarlyDetection/colorectal-cancer-early-detection-acs-recommendations. Accessed on February 15, 2015.
  3. American Society for Gastrointestinal Endoscopy. ASGE Guideline. Colorectal Cancer Screening and Surveillance (2006). Gastrointest Endosc. 2006; 63(4):546-557.
  4. American Society for Gastrointestinal Endoscopy ASGE Standards of Practice Committee. Appropriate use of gastrointestinal endoscopy. Gastrointest Endosc. 2012; 75(6):1127-1131.
  5. 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 February 15, 2015.
  6. 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 February 15, 2015.
  7. 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.
  8. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012; 143(3):844-857.
  9. NCCN Clinical Practice Guidelines in Oncology@ 2015. National Comprehensive Cancer Network, Inc. Colorectal Cancer Screening V1.2014. Revised May 19, 2014. For additional information visit the NCCN website: http://www.nccn.org/. Accessed on February 15, 2015.
  10. NCCN Clinical Practice Guidelines in Oncology@ 2015. National Comprehensive Cancer Network, Inc. Genetic/Familial High Risk Assessment. Colorectal V2.2014. Revised May 19, 2014. For additional information visit the NCCN website: http://www.nccn.org/. Accessed on February 15, 2015.
  11. Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology guidelines for colorectal cancer screening. Gastroenterology. 2008; 134(5):1570-1595.
  12. 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.
  13. Taylor DP, Burt RW, Williams MS, et al. Population-based family history-specific risks for colorectal cancer: a constellation approach. Gastroenterology. 2010; 138(3):877-885.
  14. 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.
  15. Winawer S, Fletcher R, Rex D, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence. Gastroenterology. 2003; 124(2):544-560.
  16. 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.html. Accessed on February 15, 2015.
Index

Colonoscopy
Colorectal Cancer Screening

History

Status

Date

Action

 
Revised05/07/2015Medical Policy & Technology Assessment Committee (MPTAC) review. Revisions include but are not limited to the following: Criteria divided into 5 general categories: (1) Screening -Average Risk; (2) Screening-Higher Risk; (3) Surveillance – At Risk; (4) Diagnostic; and (5) Therapeutic Colonoscopy. Section A Screening Colonoscopy - Average Risk Populations: Clarified that medically necessary criteria for average risk individuals includes sessile serrated polyps (SSPs). Added criteria for colonoscopy based on a stool based test. Removed the words "left-sided" from the criterion for individual with a personal history of hyperplastic, non-SSP less than 1 cm removed at colonoscopy. Section B Surveillance Colonoscopy - At Risk Populations revised to address individuals with a personal history of a positive stool based test. Clarified that the medically necessary criteria for adenomatous polyps includes sessile serrated polyps (SSPs). Moved a portion of the medically necessary criteria addressing serrated polyposis syndrome and a portion of criteria addressing colonic adenomatous polyposis of unknown etiology to Section B Surveillance Colonoscopy - At Risk (criteria was unchanged). Revised and moved medically necessary criteria for Inflammatory Bowel Disease to Section B Surveillance Colonoscopy-At Risk section. Section C Screening Colonoscopy in Higher Risk Populations: Revised medically necessary criteria addressing family history of colorectal cancer or adenomas and the medically necessary criteria for Lynch Syndrome. In the Not Medically Necessary section, clarified this section includes surveillance colonoscopy. Updated Description, Discussion and Reference sections.
 01/21/2015Updated Coding section with 01/01/2015 CPT and HCPCS changes; removed 45383, 45387 deleted 12/31/2014.
Revised05/15/2014MPTAC review. Expanded criteria for screening colonoscopy in average risk individuals to include those with history of hyperplastic, right-sided non-SSP. In section on screening colonoscopy in higher risk individuals, revised criteria for the following: (1) adenomatous polyps; (2) family history of colorectal cancer or adenoma and (3) inflammatory bowel disease. Added new medically necessary criteria for colonic adenomatous polyposis of unknown etiology.
Revised05/09/2013MPTAC 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