Description 
Computed tomographic (CT) colonography, also referred to as virtual colonoscopy, is used to examine the colon and rectum to detect abnormalities such as polyps and cancer. Polyps may be adenomatous (which have the potential to become malignant) or completely benign.

Colorectal cancer (CRC) is the third most common cancer and the second most common cause of cancer death in the United States. Symptoms include blood in the stool, change in bowel habit, abdominal pain, and unexplained weight loss.

Relative contraindications to CTC include symptomatic acute colitis, acute diarrhea, recent acute diverticulitis, recent colorectal surgery, symptomatic colon-containing abdominal wall hernia, and small bowel obstruction. It is not indicated in routine follow-up of inflammatory bowel disease, hereditary polyposis or non-polyposis cancer syndromes, evaluation of anal disease, or the pregnant or potentially pregnant patient. For all high-risk individuals, colonoscopy is preferred.

In addition to its use as a diagnostic test in symptomatic patients, CT colonography may be used in asymptomatic patients with a high risk of developing colorectal cancer. Conventional colonoscopy is the main method currently used for examining the colon.

GENERAL INFORMATION

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

OVERVIEW:
Request for a follow-up study — A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Policy  
INDICATIONS ^1,2,3
For diagnostic evaluation
Symptomatic patients when conventional colonoscopy is contraindicated or could not be completed

• Patient had failed or incomplete colonoscopy
• Patient has an obstructive colorectal cancer
• When colonoscopy is medically contraindicated or not possible (e.g., patient is unable to undergo sedation or has medical conditions such as a recent myocardial infarction, recent colonic surgery, a bleeding disorder, or severe lung and/or heart disease)

Follow-Up Studies

• For a 3-year follow-up when at least one polyp of 6 mm in diameter detected at CTC if patient does not undergo polypectomy (or is unwilling or unable to undergo colonoscopy)

NOTE: CT (Virtual) Colonoscopy is not indicated in routine follow-up of inflammatory bowel disease, hereditary polyposis or non-polyposis cancer syndromes, evaluation of anal disease, or the pregnant or potentially pregnant patient. 

References 

1. American College of Radiology. ACR Appropriateness Criteria® Colorectal Cancer Screening. American College of Radiology. Updated 2018. Accessed December 29, 2022. https://acsearch.acr.org/docs/69469/Narrative/
2. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Colorectal Cancer Screening Version 3.2022. National Comprehensive Cancer Network (NCCN). Updated September 30, 2022. Accessed December 29, 2022. https://www.nccn.org/professionals/physician_gls/pdf/colorectal_screening.pdf
3. Rex DK, Boland CR, Dominitz JA, et al. Colorectal Cancer Screening: Recommendations for Physicians and Patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. Jul 2017;112(7):1016-1030. doi:10.1038/ajg.2017.174

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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