SUPERSEDED Local Coverage Determination (LCD)

Virtual Colonoscopy (CT Colonography)

L34055

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.
Superseded
To see the currently-in-effect version of this document, go to the section.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34055
Original ICD-9 LCD ID
Not Applicable
LCD Title
Virtual Colonoscopy (CT Colonography)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/06/2022
Revision Ending Date
10/04/2023
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

N/A

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Indications

CT colonography, also known as virtual colonoscopy utilizes helical computed tomography of the abdomen and pelvis along with 2D or 3D reconstruction to visualize the colon lumen. The test requires colonic preparation similar to that required for instrument (fiberoptic, video) colonoscopy, as well as air insufflation to achieve colonic distention.

Virtual colonoscopy is only indicated in those patients in whom a diagnostic or surveillance instrument colonoscopy of the entire colon is incomplete due to an inability to fully pass the colonoscope proximally, and a repeat attempt is not indicated. Virtual colonoscopy is intended for use in pre-operative planning only when imaging of the non-visualized colon proximal to the obstruction is medically necessary in making decisions involving the approach to the patient.

Incomplete colonoscopy must be due to one of the following:

1. An obstructing neoplasm,

2. Intrinsic scarring, stricture, aberrant anatomy, or obstruction from prior surgery, radiation, or diverticular disease.

3. Extrinsic compression.

4. Patient safety. There are few absolute contraindications to instrument colonoscopy. Relative contraindications do not create medical necessity for using virtual colonoscopy as a screening procedure, and the above indications must still be met.

The following relative contraindications to instrument colonoscopy may be indications for virtual colonoscopy if well documented in the medical record and the patient's primary physician and the colonoscopist agree on the increased risk to the patient:


    • Severe coagulopathy

 

    • Long-term anticoagulation

 

    • Increased sedation risk (such as from severe COPD or previous anesthesia adverse reaction)





Limitations
Virtual colonoscopy is not covered when used for screening, or in the absence of signs or symptoms of disease, regardless of family history or other risk factors for the development of colonic disease.

Virtual colonoscopy is not covered when used as an alternative to instrument colonoscopy for screening or in the absence of signs or symptoms of disease.

Virtual colonoscopy is not covered following incomplete colonoscopy if the reason for the colonoscopy is other than one of those described above.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be available to Medicare on request.

1. The results of an incomplete instrument colonoscopy that resulted in the order for the CT colonography (virtual colonoscopy)must be retained in the patient's medical record. Similarly, documentation of the presence and severity of a relative contraindication as justification for a CT colonographic examination must be retained in the medical record.

2. The order/prescription from the referring physician must be retained in the patient's medical record.



Services performed for excessive frequency are not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation.

Sources of Information

The development and coverage guidelines in this policy were based on a review of pertinent medical literature, policies from other Medicare contractors, and discussions with appropriate specialists.

Blue Cross Blue Shield Association Technology Evaluation Center. CT Colonography (“Virtual Colonoscopy") for Colon Cancer Screening. Assessment Program Volume 19, No.6 July 2004.

Cotton P et al. Computed Tomographic Colonography (Virtual Colonoscopy): A Multicenter Comparison with Standard Colonoscopy for Detection of Colorectal Neoplasia. JAMA 2004; 291:1713-9.

Fenlon H et al. Occlusive Colon Carcinoma: Virtual Colonoscopy in the Preoperative Evaluation of the Proximal Colon. Radiology 1999; 210: 423-8.

Gluecker T et al. Colorectal Cancer Screening with CT Colonography, Colonoscopy, and Double-Contrast Barium Enema Examination: Prospective Assessment of Patient Perception and Preferences. Radiology 2003; 227(2)378-84.

Isenberg G et al. Virtual colonoscopy. Gastrointest Endosc 2003; 57: 451-4.

Laghi A et al. Computed Tomographic Colonography (Virtual Colonoscopy): Blinded Prospective Comparison with Conventional Colonoscopy for the Detection of Colorectal Neoplasia. Endoscopy 2002; 34:441-6.

Laghi A et al. Detection of Colorectal Lesions with Virtual Computed Tomographic Colonography.Am J Surgery 2002;183:124-31.

Macari M et al. Colorectal Neoplasms: Prospective Comparison of Thin-Section Low Dose Multi-Detector Row CT Colonography and Conventional Colonoscopy for Detection. Radiology 2002;224(2):383-92.

Morrin M et al. Endoluminal CT Colonography After an Incomplete Endoscopic Colonoscopy. AJR 1999;172:913-8.

Mulhall B et al. Meta-Analysis: Computed Tomographic Colonography. Ann Intern Med 2005;142:635-50.

Neri E et al. Colorectal Cancer: Role of CT Colonography in Preoperative Evaluation after Incomplete Colonoscopy. Radiology 2002;223(3):615-19.

Pickhardt P et al. Computed Tomographic Virtual Colonoscopy to Screen for Colorectal Neoplasia in Asymptomatic Adults. N Engl J Med 2003;349(23):2191-200.

Pickhardt P. Three-Dimensional Endolumenal CT Colonography (Virtual Colonoscopy): Comparison of Three Commercially Available Systems. AJR 2003;181(6):1599-606.

Ransohoff D. Virtual Colonoscopy - What It Can Do vs What It Will Do. JAMA 2004;291:1772-74.

Sun C et al. Assessment of Spiral CT Pneumocolon in Preoperative Colorectal Carcinoma. World J Gastroenterol 2005;11:3866-870.

Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/06/2022 R11

R12

Revision Effective: 10/06/2022

Revision Explanation: Annual Review, no changes made

09/26/2022: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
09/30/2021 R10

R11

Revision Effective: 09/30/2021

Revision Explanation: Annual Review, no changes made

09/22/2021: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
09/26/2019 R9

R10

Revision Effective: N/A

Revision Explanation: Annual Review, no changes made

09/15/2020: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
09/26/2019 R8

R9

Revision Effective: 09/26/2019

Revision Explanation: Annual Review, no changes made

09/26/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (annual review, no changes)
09/19/2019 R7

R8

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901. For Approval, no changes.

09/13/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To Code Removal
09/19/2019 R6

R7

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901.

09/12/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To Code Removal
10/01/2017 R5

R6

Revision Effective: 8-5-2019

Revision Explanation: Removed all billing and coding details from policy into related Billing and Coding article. Coding information was removed based on CR10901.

08/05/2019-At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Removed billing and coding based on CR10901)
10/01/2017 R4

R5

Revision Effective: N/A

Revision Explanation: annual review no changes made.

09/27/2018-At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

R4
Revision Effective: N/A
Revision Explanation: Annual review no changes made.

  • Other (Annual Review)
10/01/2017 R3

R3
Revision Effective: 10/01/2017
Revision Explanation: during ICD-10 annual update codes K56.5, K56.60, and K56.69 were deleted and replaced with the following: K56.50, K56.51, K56.52, K56.600, K56.601, K56.609, K56.690, K56.691, K56.699.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R2 R2
Revision Effective: N/A
Revision Explanation: Annual review no changes made.
  • Other (Annual review)
10/01/2015 R1 R1
Revision Effective: N/A
Revision Explanation: Annual review no changes made.
  • Other (Annual Review)
N/A

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
09/29/2023 10/05/2023 - N/A Currently in Effect View
09/26/2022 10/06/2022 - 10/04/2023 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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