Select a hyperlink below to be directed to that section. COVERAGE GUIDELINE CODING RELATED INFORMATION REFERENCES HISTORY

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1 BENEFIT COVERAGE GUIDELINE Colonoscopy Effective Date: March 1, 2018 Last Revised: Feb. 6, 2018 Replaces: N/A RELATED MEDICAL POLICIES: Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes Select a hyperlink below to be directed to that section. COVERAGE GUIDELINE CODING RELATED INFORMATION REFERENCES HISTORY Clicking this icon returns you to the hyperlinks menu above. Introduction A colonoscopy uses a flexible lighted tube to examine the colon and rectum. A colonoscopy can be used as a preventive test to screen for colon cancer or polyps. It can also be done as a diagnostic procedure when symptoms or lab tests suggest there might be a problem in the rectum or colon. In some cases, minor procedures may be done during a colonoscopy, such as taking a biopsy or destroying an area of unhealthy tissue (a lesion). Preventive colonoscopy is done for people who are not having any symptoms or problems with the colon or rectum. The decision to do a preventive colonoscopy is usually based on age and family history. The US Preventive Services Task Force has highly recommended that all adults be screened for colon cancer between the ages of 50 and 75. This guideline applies only to people of average risk. Colonoscopy is only one of the screening tests that can be used. This benefit coverage guideline provides general information about how the health plan decides whether a colonoscopy is covered under the preventive or diagnostic (medical) benefits. Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered. Coverage Guideline

2 Indication Preventive screening colonoscopy Medical colonoscopy (eg, diagnostic, therapeutic, surveillance) Not medically necessary indications for diagnostic colonoscopy 3 Coverage Statement Preventive screening colonoscopy procedures are covered under the preventive care benefits in plans that include a preventive benefit. Preventive screenings are for people that are at average risk and have no symptoms. The original intent of the colonoscopy determines the benefit under which it is paid. A colonoscopy done for screening in the absence of symptoms, based on age and risk factors, is covered under the preventive benefit even if polyps or other abnormalities are found and removed or treated. Medical colonoscopy procedures are covered under the medical benefits. A medical colonoscopy for a specific illness, injury or a set of symptoms is considered diagnostic, therapeutic, or a surveillance procedure A colonoscopy for individuals who have an increased or high risk of polyps or a current or prior diagnosis of colon cancer is considered surveillance after the initial study Diagnostic colonoscopy is generally not indicated for the following conditions: Acute diarrhea Chronic abdominal pain Chronic, stable irritable bowel syndrome Routine follow-up of inflammatory bowel disease except for cancer surveillance in chronic ulcerative colitis and Crohn colitis* Upper GI tract bleeding or melena with a demonstrated upper GI source *Note: See note on Screening colonoscopy under Coding for IBD Coding Page 2 of 8

3 Correctly coding screening colonoscopies is essential to ensure accurate payment. The codes below are used by the plan to identify screening colonoscopies and associated services. Codes ICD (CM) Diagnosis (to ensure accurate reimbursement it is recommended to bill one of the diagnosis codes listed below in the PRIMARY diagnosis field) Colonoscopy Screening for patients at average risk beginning at age 50: CPT: 45378, 45380, 45381, 45384, 45385, 45388, 45390, HCPCS: G0105, G0121 Sedation CPT: 00812, 99152, HCPCS: G0500 Z12.10, Z12.11, Z12.12, Z80.0, Z83.71, Z83.79 Screening for patients under age 50, at increased risk for colon cancer due to a strong family history of colon cancer: Z80.0, Z83.71, Z83.79, Z84.81 Screening colonoscopy for patients with personal history of inflammatory bowel disease (Crohn disease or ulcerative colitis) will be recognized as preventive with a screening diagnosis in the primary position, and a disease specific diagnosis in secondary position: Z12.10, Z12.11, Z12.12 Pathology CPT: (colon polyp(s)) Colonoscopy Consultation HCPCS: S0285* *For services on and after 1/1/17 D12.6, D37.4, D49.0, K63.5 Z12.10-Z12.12, Z84.81 No diagnosis code required with S0285 Pre-Operative Assessment CPT: 99202, 99212** **These CPT codes will only be accepted for services delivered prior to 1/1/17, when associated diagnosis code is submitted. Note: Z12.10-Z12.12 CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS). Page 3 of 8

4 Coding Screening Colonoscopy Services Benefit coverage for a given colonoscopy procedure is based on a combination of the procedure code (CPT, HCPCS) and the diagnosis code (ICD-10) selected by the provider and submitted on the claim. A colonoscopy procedure may be covered as a preventive screening or a medical intervention for identified symptoms or findings. This guideline provides clinical indications for determining whether a colonoscopy is preventive or medical. Screening, diagnostic, and surveillance indications for colonoscopy are based on guidelines from a variety of specialty societies and government organizations. Ancillary Colonoscopy Services Effective 01/01/2016, all non-grandfathered (NGF) health plans will provide coverage for ancillary services directly associated with a covered screening colonoscopy, including: The professional charge for the provider performing the colonoscopy A pre-procedure evaluation Facility or ambulatory surgical center services Anesthesia services, when medically necessary Pathologist services to evaluate any polyps removed during the screening colonoscopy Related Information Professional Guidelines for a Preventive Screening Colonoscopy Based on Risk Stratification Risk level American Cancer Society (ACS) National Comprehensive Cancer Network (NCCN) Average risk Individuals with no first-degree relatives having a history of CRC or adenomatous polyps and has not experienced these problems personally. Individuals 50 years or older with no personal history of adenoma or colorectal cancer, or inflammatory bowel disease and a negative family Page 4 of 8

5 Risk level American Cancer Society (ACS) National Comprehensive Cancer Network (NCCN) history. Increased risk Hereditary/high risk CRC: Colorectal cancer Individuals who have a personal history of CRC or adenomas, a family history of CRC or adenomas diagnosed in any first-degree relative before age 50, or in two or more first-degree relatives diagnosed at any age (if not a hereditary syndrome). According to the ACS, individuals who have a personal history of CRC or adenomatous polyp require regular surveillance, not screening. Individuals who have a personal history of CRC or adenomas, a family history of CRC or adenomas diagnosed in any first-degree relative before age 50, or in two or more first-degree relatives diagnosed at any age (if not a hereditary syndrome). According to the ACS, individuals who have a personal history of CRC or adenomatous polyp require regular surveillance, not screening. Individuals with personal history of adenomatous polyps/sessile serrated polyps (SSP), colorectal cancer (CRC), or inflammatory bowel disease as well as those with a positive family history of CRC or advanced adenomatous polyps. Individuals who have had CRC before the age of 50 years; those with family history of multiple cases of CRC or HNPCC related cancers; personal or family history of polyposis; or individuals with HNPCC/Lynch syndrome. Definition of Terms Colonoscopy: A colonoscopy is a procedure that permits the direct examination of the mucosa of the entire colon by using a flexible lighted tube. The procedure is done with sedation in a hospital outpatient department, in a clinic, or an office facility. During the colonoscopy a doctor can biopsy and remove pre-cancerous polyps and some early stage cancers and also diagnose other conditions or diseases. General definitions of procedure indications from various specialty societies, including the ACA: A screening colonoscopy is done to look for disease, such as cancer, and treat early conditions, if indicated, in people without symptoms. A diagnostic colonoscopy is done to confirm or rule out a condition in a person who is symptomatic or who is believed to have a specific condition based on other clinical information. A surveillance colonoscopy is the follow-up to check for the return of a disease in a person who was previously treated for the disease and is now believed to be free of the disease. Page 5 of 8

6 Patient Protection and Affordable Care Act (PPACA): The comprehensive health care reform law enacted in March The Affordable Care Act included 10 essential benefits that must be covered by all health insurance plans including preventive and wellness services. Preventive health services: Health care services designated for the prevention and early detection of illness in asymptomatic people. This generally includes routine physical examinations, screening examinations, tests, immunizations, and counseling designed to maintain and improve health. Note: Preventive medicine evaluation and management (E/M) services have specific preventive medicine CPT codes. Preventive intervention: Interventions provided to people who have signs of health risks in order to prevent or delay the onset of illness or injury. This includes taking action to modify an effect, to prevent or slow the course of illness or disease through behavior and or lifestyle changes, and to increase patient participation in health outcomes and disease management. U.S. Preventive Services Task Force (USPSTF): An independent panel of non-federal experts in prevention and evidence-based medicine composed of primary care providers. The USPSTF grades its recommendations based on the strength of evidence and magnitude of net benefit (benefits minus harms). These guidelines are for average risk individuals. The Plan covers USPSTF recommendations graded A or B as preventive benefits on most plans offered. Alaska State Statute Alaska has a specific state statute (AS ) that requires health care insurers to provide insurance coverage for the costs of colorectal cancer screening examinations and laboratory tests as specified in the American Cancer Society guidelines for colorectal cancer screening of asymptomatic individuals. Coverage shall be provided for all colorectal screening examinations and tests that are administered at a frequency identified in the American Cancer Society guidelines for colorectal cancer. More information regarding covered and non-covered services and other administrative criteria is found at: Oregon State Statute Oregon has a specific state law (House bill 2560) that requires health benefit plans to provide coverage for all colorectal screening examinations and laboratory tests assigned either a grade of A or a grade of B by the United States Preventive Services Task Force (USPSTF). More information regarding covered and non-covered services and other administrative criteria can Page 6 of 8

7 be found at the following link: References 1. American Cancer Society recommendations for colorectal cancer early detection. Revised 02/05/2015. Available at URL: ectal-cancer-early-detection-acs-recommendations. Accessed February 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 May-Jun;58(3): PMID: American Society for Gastrointestinal Endoscopy ASGE Standards of Practice Committee. Appropriate use of gastrointestinal endoscopy. Gastrointest Endosc. 2012; 75(6): Available at URL: Accessed February Centers for Medicare and Medicaid Services. National Coverage Determination for Colorectal Cancer Screening Tests. NCD # Effective October 9, Available at: Accessed February NCCN Clinical Practice Guidelines in Oncology National Comprehensive Cancer Network, Inc. Colorectal Cancer screening v Available at URL: (Note: accessing this content requires login information.) Accessed February NCCN Clinical Practice Guidelines in Oncology National Comprehensive Cancer Network, Inc. Genetic/Familial High Risk Assessment: Colorectal v Available at URL: Note: accessing this content requires login information.) Accessed February U.S. Preventive Services Task Force. Screening for colorectal cancer. US Preventive Service Task Force recommendation statement. Ann Intern Med 2008; 149(9): Available at URL: Accessed February Index. U.S. Preventive Services Task Force. December Available at URL: Accessed February Premera Blue Cross Clinical Practice Guidelines. Available at URL: Accessed February History Page 7 of 8

8 Date Comments 01/12/16 New Benefit Coverage Guideline. This guideline provides the indications for colonoscopy services based on whether the procedure is a preventive screening or medical intervention for a known condition. State regulations that may impact coverage are included in the additional information. 07/01/16 Interim update, approved June 14, Clarified statement under Preventive Screening to indicate benefits will be paid based on intent: e.g., if a screening colonoscopy is performed and polyps are discovered and removed/biopsied, services will be paid as preventive screening. 12/09/16 Policy moved to new format. No changes to content or coverage. 04/19/17 Coding update. HCPCS code S0285 added to policy for preventive services 1/1/17 and beyond; CPT codes and no longer accepted after 12/31/16 for preventive services, as noted in Coding section. 05/01/17 Annual review; changes approved April 11, No change to benefit coverage guideline statements. Added CPT codes 45381, and /13/17 Coding update, removed diagnosis codes Z00.00 and Z /01/17 Coding update, added CPT codes and /07/17 Coding update, added HCPCS code G /01/18 Annual Review, approved February 6, Minor edits for clarity. Intent of guideline unchanged. Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA) Premera All Rights Reserved. Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage. Page 8 of 8

9 Discrimination is Against the Law LifeWise Health Plan of Oregon complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. LifeWise does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. LifeWise: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact the Civil Rights Coordinator. 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10 日本語 (Japanese): この通知には重要な情報が含まれています この通知には LifeWise Health Plan of Oregon の申請または補償範囲に関する重要な情報が含まれている場合があります この通知に記載されている可能性がある重要な日付をご確認ください 健康保険や有料サポートを維持するには 特定の期日までに行動を取らなければならない場合があります ご希望の言語による情報とサポートが無料で提供されます (TTY: ) までお電話ください 한국어 (Korean): 본통지서에는중요한정보가들어있습니다. 즉이통지서는귀하의신청에관하여그리고 LifeWise Health Plan of Oregon 를통한커버리지에관한정보를포함하고있을수있습니다. 본통지서에는핵심이되는날짜들이있을수있습니다. 귀하는귀하의건강커버리지를계속유지하거나비용을절감하기위해서일정한마감일까지조치를취해야할필요가있을수있습니다. 귀하는이러한정보와도움을귀하의언어로비용부담없이얻을수있는권리가있습니다 (TTY: ) 로전화하십시오. ລາວ (Lao): ແຈ ງການນ ມ ຂ ມ ນສ າຄ ນ. ແຈ ງການນ ອາດຈະມ ຂ ມ ນສ າຄ ນກ ຽວກ ບຄ າຮ ອງສະ ໝ ກ ຫ ຄວາມຄ ມຄອງປະກ ນໄພຂອງທ ານຜ ານ LifeWise Health Plan of Oregon. ອາດຈະມ ວ ນທ ສ າຄ ນໃນແຈ ງການນ. ທ ານອາດຈະຈ າເປ ນຕ ອງດ າເນ ນ ການຕາມກ ານ ດເວລາສະເພາະເພ ອຮ ກສາຄວາມຄ ມຄອງປະກ ນສ ຂະພາບ ຫ ຄວາ ມຊ ວຍເຫ ອເລ ອງຄ າໃຊ ຈ າຍຂອງທ ານໄວ. ທ ານມ ສ ດໄດ ຮ ບຂ ມ ນນ ແລະ ຄວາມ ຊ ວຍເຫ ອເປ ນພາສາຂອງທ ານໂດຍບ ເສຍຄ າ. ໃຫ ໂທຫາ ភ ស ខមរ (Khmer): សចកត ជ នដ ណ ង ន ម នព ត ម នយ ងស ខ ន សចកត ជ នដ ណ ង ន រប ហល ជ ម នព ត ម នយ ងស ខ ន អ ព ទរមង បបបទ ឬក ររ ប រងរបស អនកត មរយ LifeWise Health Plan of Oregon រប ហលជ ម ន ក លបរ ចឆទស ខ ន ន កន ង សចកត ជ នដ ណ ង ន អនករប ហលជ រត វក រប ញច ញសមតថភ ព ដល ក ណត ថង ជ ក ចប ស ន ន ដ មប ន ងរកស ទ កក រធ ន រ ប រងស ខភ ពរបស អនក ឬរប ក ជ ន យ ចញ ថល អនកម នស ទធ ទទ លព ត ម ន ន ន ងជ ន យ ន កន ងភ ស របស អនក ដ យម នអសល យ ឡ យ ស មទ រស ពទ (TTY: ) ਪ ਜ ਬ (Punjabi): ਇਸ ਨ ਟਸ ਵਚ ਖ ਸ ਜ ਣਕ ਰ ਹ. ਇਸ ਨ ਟਸ ਵਚ LifeWise Health Plan of Oregon ਵਲ ਤ ਹ ਡ ਕਵਰ ਜ ਅਤ ਅਰਜ ਬ ਰ ਮਹ ਤਵਪ ਰਨ ਜ ਣਕ ਰ ਹ ਸਕਦ ਹ. ਇਸ ਨ ਜਸ ਜਵਚ ਖ ਸ ਤ ਰ ਖ ਹ ਸਕਦ ਆ ਹਨ. ਜ ਕਰ ਤ ਸ ਜਸਹਤ ਕਵਰ ਜ ਰ ਖਣ ਹ ਵ ਜ ਓਸ ਦ ਲ ਗਤ ਜ ਵ ਚ ਮਦਦ ਦ ਇਛ ਕ ਹ ਤ ਤ ਹ ਨ ਅ ਤਮ ਤ ਰ ਖ਼ ਤ ਪ ਹਲ ਕ ਝ ਖ ਸ ਕਦਮ ਚ ਕਣ ਦ ਲ ੜ ਹ ਸਕਦ ਹ,ਤ ਹ ਨ ਮ ਫ਼ਤ ਵ ਚ ਤ ਆਪਣ ਭ ਸ਼ ਵ ਚ ਜ ਣਕ ਰ ਅਤ ਮਦਦ ਪ ਰ ਪਤ ਕਰਨ ਦ ਅ ਧਕ ਰ ਹ,ਕ ਲ (Farsi): فارسی اين اعالميه حاوی اطالعات مھم ميباشد.اين اعالميه ممکن است حاوی اطالعات مھم درباره فرم تقاضا و يا پوشش بيمه ای شما از طريق LifeWise Health Plan of Oregon باشد. به تاريخ ھای مھم در اين اعالميه توجه نماييد.شما ممکن است برای حقظ پوشش بيمه تان يا کمک در پرداخت ھزينه ھای درمانی تان به تاريخ ھای مشخصی برای انجام کارھای خاصی احتياج داشته باشيد.شما حق اين را داريد که اين اطالعات و کمک را به زبان خود به طور رايگان دريافت نماييد. برای کسب اطالعات با شماره (کاربران TTY تماس باشماره ) تماس برقرار نماييد. Polskie (Polish): To ogłoszenie może zawierać ważne informacje. To ogłoszenie może zawierać ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń poprzez LifeWise Health Plan of Oregon. Prosimy zwrócic uwagę na kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod Português (Portuguese): Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio do LifeWise Health Plan of Oregon. Poderão existir datas importantes neste aviso. Talvez seja necessário que você tome providências dentro de determinados prazos para manter sua cobertura de saúde ou ajuda de custos. Você tem o direito de obter esta informação e ajuda em seu idioma e sem custos. Ligue para Română (Romanian): Prezenta notificare conține informații importante. Această notificare poate conține informații importante privind cererea sau acoperirea asigurării dumneavoastre de sănătate prin LifeWise Health Plan of Oregon. Pot exista date cheie în această notificare. Este posibil să fie nevoie să acționați până la anumite termene limită pentru a vă menține acoperirea asigurării de sănătate sau asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste informații și ajutor în limba dumneavoastră. Sunați la Pусский (Russian): Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через LifeWise Health Plan of Oregon. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону Fa asamoa (Samoan): Atonu ua iai i lenei fa asilasilaga ni fa amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei fa asilasilaga o se fesoasoani e fa amatala atili i ai i le tulaga o le polokalame, LifeWise Health Plan of Oregon, ua e tau fia maua atu i ai. Fa amolemole, ia e iloilo fa alelei i aso fa apitoa olo o iai i lenei fa asilasilaga taua. Masalo o le a iai ni feau e tatau ona e faia ao le i aulia le aso ua ta ua i lenei fa asilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo olo o e iai i ai. Olo o iai iate oe le aia tatau e maua atu i lenei fa asilasilaga ma lenei fa matalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni Español (Spanish): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de LifeWise Health Plan of Oregon. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng LifeWise Health Plan of Oregon. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa ไทย (Thai): ประกาศน ม ข อม ลส าค ญ ประกาศน อาจม ข อม ลท ส าค ญเก ยวก บการการสม ครหร อขอบเขตประก น ส ขภาพของค ณผ าน LifeWise Health Plan of Oregon และอาจม ก าหนดการในประกาศน ค ณ อาจจะต องด าเน นการภายในก าหนดระยะเวลาท แน นอนเพ อจะร กษาการประก นส ขภาพของค ณหร อการ ช วยเหล อท ม ค าใช จ าย ค ณม ส ทธ ท จะได ร บข อม ลและความช วยเหล อน ในภาษาของค ณโดยไม ม ค าใช จ าย โทร (TTY: ) Український (Ukrainian): Це повідомлення містить важливу інформацію. Це повідомлення може містити важливу інформацію про Ваше звернення щодо страхувального покриття через LifeWise Health Plan of Oregon. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на Вашій рідній мові. 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