BlueCross and BlueShield of Montana Medical Policy/Codes
Virtual Endoscopy, Including Virtual Colonoscopy
Chapter: Medicine: Tests
Current Effective Date: March 15, 2014
Original Effective Date: August 14, 2008
Publish Date: January 14, 2014
Revised Dates: March 1, 2010; June 11, 2012; August 30, 2013; January 14, 2014
Description

Virtual Colonoscopy (VC)

Colorectal cancer (CRC) is the second leading cancer killer in the United States. Experts believe over 90% of all CRCs can be cured through early detection and treatment; thus the recommendation that Americans 50 years and older be screened for CRC. If there is a tendency toward colon cancer in the family, as evidenced by a close relative with either adenomas or cancer, it is advised to start ten years earlier and use a more sensitive and specific technique. Most professionals consider optical colonoscopy (OC), (also known as fiberoptic, endoscopic, conventional or traditional colonoscopy) the gold standard for CRC screening as it allows for complete and direct visualization of the entire colon, thereby providing the opportunity to identify precancerous polyps and cancer, and then to do diagnostic biopsies or therapeutic removal of these lesions, all in one setting.

Virtual colonoscopy (VC), (also known as virtual computed tomography colonoscopy [CTC], magnetic resonance colonography [MRC], computed tomography colonoscopy or colonography [CTC]), is an emerging, minimally invasive, new technique. VC uses data generated from computed tomography (CT) scan or magnetic resonance imaging (MR, MRI) to create two- or three- dimensional (2-D or 3-D) scans of the colon.

The U.S. Food and Drug Administration (FDA) first cleared computer assisted technology in 1995. VC is actually a post-processing or off-line method, which allows for reconstruction of the inner bowel surface structures from the most commonly, used Helical CT data sets. VC has been investigated as an alternative to OC, specifically as an alternative screening technique for colon cancer.

The patient follows a regimen of cleansing the bowel, similar to the OC regimen. There is no sedation and the exam is less time-consuming. The patient may be given an iodinated contrast to “stool tag” polyps for increased visualization during the imaging examination. An air enema (gas insufflation), which may be uncomfortable to the patient, is administered to distend the colon, allowing the polyps to stand out from the normal colon surface, followed by the CT scanning or MRI. The images (approximately 600 to 1,000) gathered extend from the lowest part of the colon (rectum) all the way to the lower end of the small intestine. The actual scan takes about 30 seconds with the patient lying on their back and then once more lying face down. The entire procedure takes less than five minutes, and since sedation is usually not necessary, the patient can leave immediately after the scanning has been completed. At a conventional computer workstation, sophisticated software combines the data to produce the 2-D (for general reviews) or 3-D (for focused reviews) image of the colon. The radiologist conducts a virtual examination of the bowel, simulating the traditional endoscopic evaluation.

Now with later software versions, the digital transfer and reconstruction are automated in “real time.” Radiologists can “fly” inside the images, identifying polyps, cancers, or other structural abnormalities. According to some clinical studies, the scans are detailed enough to reveal cell changes, such as polyps (tiny precancerous and cancerous growths) or adenomas (benign growths), of the intestinal mucosa as small as six millimeters (mm) in diameter. If abnormalities are present, the patient will have a follow-up OC examination. This is a drawback of this technology because, unless a follow-up OC examination is performed within a few hours of the VC, the patient would need to repeat the bowel cleansing regimen.

Research efforts are improving the accuracy of VC, one of which is computed tomography colonography computer-aided detection (CTC CAD), currently under development at the National Institutes of Health (NIH) as an aid to radiologist to improve early polyp detection. Computed-aided detection (CAD) software for VC serves as a second review, identifying sites warranting closer inspection by the radiologist.

In 2008, the American Cancer Society (ACS) along with the U.S. Multi Society Task Force on Colorectal Cancer and the American College of Radiology (ACR) has released joint consensus guidelines for CRC screening for average-risk adults. The new guidelines recommend that the stool DNA test and the VC are now acceptable forms of CRC screening for average-risk adults.

To assess the patient’s risk or degree of “sickness” or “physical state” prior to a procedure, such as a colonoscopy, the “ASA Physical Status (PS) Classification System” is utilized. The following “ASA Physical Status Classification System” is from the American Society of Anesthesiologists:

P1 (PS1)

A normal healthy patient

P2 (PS2)

A patient with mild systemic disease

P3 (PS3)

A patient with severe systemic disease

P4 (PS4)

A patient with severe systemic disease that is a constant threat to life

P5 (PS5)

A moribund patient who is not expected to survive without the operation

P6 (PS6)

A declared brain-dead patient whose organs are being removed for donor purposes

NOTE:  These definitions appear in each annual edition of the ASA Relative Value Guide. There is no additional information that will help you further define these categories.

Virtual Gastroscopy (VG)

Early gastric cancer (EGC) is defined as a carcinoma in which invasion is limited to the mucosa and submucosa, regardless of lymph node status and distant metastasis. (22) Gastric cancer is the fourth most common cancer worldwide, with surgery being the first-line therapy. Patients with advanced gastric cancer (AGC) have a 5-year survival rate of 7%-27%, whereas those with EGC have a 5-year survival rate of 85%-100%. Early detection and accurate preoperative staging of EGC are important because these patients may be ideal candidates for minimally invasive surgeries. Barium examination and conventional optical endoscopy (OE) are the standard for diagnostic and evaluation of gastric lesions. OE allows for the visualization of fine details in the mucosa and ability to biopsy of suspected lesions in the same operative setting. (22, 23)

Virtual gastroscopy (VG), (also known as virtual upper gastrointestinal endoscopy, computed tomography gastrography [CTG], and has been interchangeably described as virtual endoscopy [VE]), is a noninvasive procedure that uses 3-D and CT, with workstation software conversions of the data, to capture detailed pictures of the inside surfaces of the gastrointestinal organs. MRI can also be used to perform VUE. (23)

In addition to using VG in detection and staging of EGC, VG has been utilized to determine the cause of symptoms, such as nausea, gastric reflux, abdominal pain, unexplained weight loss, and identification of inflammation, precancerous conditions, and hernia. No anesthesia is required for VG. A disadvantage of VG, along with inability to directly view the mucosa and inability to obtain a biopsy, is the concern of exposure to CT scan radiation. (23)

Virtual Uro-Endoscopy (VUE)

Virtual uro-endoscopy (VUE), (also known as virtual cystoscopy, computed tomography urinary cystoscopy [CTUC]), is a noninvasive procedure using the 3-D and CT or MRI, with workstation software conversions of the data, to provide endoluminal navigation and images. (27, 28)

VUE has been used to explore the renal pelvis, ureter, and urethra, detect bladder tumors, and as long-term follow-up of patients with ureteropelvic junction obstruction, urinary bladder cancer, and ureteral and/or urethral strictures, stenosis, or obstructions. (28) As with the other virtual endoscopic procedures discussed regarding visualization, radiation exposure, and ability to perform biopsies, the problems encountered with using the VUE method result from poor sensitivity for lesions smaller than 0.5 cm, for carcinoma in situ, and for ureteral calculi. (27)

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Virtual Colonoscopy (VC)

Virtual colonoscopy (VC), with or without computer-aided-detection (CAD), is considered not medically necessary (See EXCEPTION, below) as a screening, diagnostic or surveillance procedure, as the clinical outcomes with this strategy have not been shown to be superior to other approaches, including the standard conventional (optical) colonoscopy (OC).

EXCEPTION:  However, VC, with or without CAD, may be considered medically necessary in patients:

  • Who cannot undergo standard conventional OC, as in colonic stenosis or obstruction, OR
  • For whom standard conventional OC is contraindicated, including, but not limited to the following medical reasons:
    1. Anticoagulation therapy, OR
    2. Increased anesthesia risk, classified by the American Society of Anesthesiologists (ASA), as level P3 and higher.

Virtual Gastroscopy (VG)

Virtual gastroscopy (VG) is considered experimental, investigational, and/or unproven as a screening, detection, evaluation or surveillance procedure for any upper gastrointestinal lesions.

Virtual Uro-Endoscopy (VUE)

Virtual uro-endoscopy (VUE) is considered experimental, investigational, and/or unproven as a screening, detection, evaluation or surveillance procedure for any urinary tract lesion, stenosis, obstruction, or stricture.

Policy Guidelines

There are new Category I CPT codes for VC (74263 – screening, 74261 and 74262 – diagnostic), but VC could be coded using the CPT for abdominal CT scans alone and may be difficult to identify VC services. In addition, CT of abdomen and 3-D or holographic reconstruction of CT are frequently billed together.

Rationale

This policy was created in 2008 and has since been updated periodically with literature review through September 2013. The following is a summary of the key literature to date.

Virtual Colonoscopy (VC)

Colon cancer screening prevents morbidity from colon cancer by the detection of early colorectal cancers (CRC) and the detection and removal of cancer precursors such as polyps. The detection of cancer and removal of polyps initially or ultimately require an optical colonoscopy (OC). Virtual colonoscopy (VC) or computed tomography (CT) colonography (CTC) is an imaging procedure that can identify cancers or polyps. The effectiveness and efficiency of VC is dependent on its capability to accurately identify cancer or polyps, so that all or most patients who have such lesions are appropriately referred for colonoscopy for ultimate diagnosis and treatment and that polyps or cancer are not falsely identified.

There are a few technical and practical problems surfacing from the clinical studies of patients undergoing a VC or an OC. There is an inability of VC to: 

  • Provide texture/color, which results in problems in identifying flat lesions (perceptual errors);
  • Adjust in the presence of retained or adherent fecal matter that may result in a false positive diagnosis (meticulous bowel preparation is required as in a OC); and/or
  • Compensate for collapsed segments of bowel resulting in the inability of evaluating the colon during image reconstruction (inadequate colon distention).

Diagnostic accuracy of VC

The diagnostic characteristics of VC as a colon cancer screening test have been investigated in many studies in which patients who are referred for OC agree to first undergo a VC. Using a second-look unblinded colonoscopy aided by the results of the VC as the reference standard, the diagnostic characteristics of VC and the blinded colonoscopy can be calculated and compared. The sensitivity of VC is a function of the size of the polyp; sensitivity is poorer for smaller polyps. A 2004 Blue Cross Blue Shield Association (BCBSA) Technology Evaluation Center (TEC) Assessment (1) found variable sensitivity and specificity of VC at that time, with many studies showing poor sensitivity. A subsequent meta-analysis of studies that examined the diagnostic performance of VC showed variation between studies but increasing sensitivity for larger polyps. (2) Sensitivity was 48% for detection of polyps smaller than 6 mm, 70% for polyps 6 to 9 mm, and 85% for polyps larger than 9 mm. Characteristics of the CT scanner explained some of the variation between studies. In contrast, specificity was homogeneous (92% for detection of polyps smaller than 6 mm, 93% for polyps 6 to 9 mm, and 97% for polyps larger than 9 mm).

Diagnostic performance of VC is highly dependent on the technology and techniques used. Thus, many of the older studies reviewed may no longer represent currently possible diagnostic performance of the test. A large study published in 2003 showed diagnostic test performance of VC for polyps to be equivalent to that of OC. (3) Other studies showed variable performance, with 2 large studies showing much lower sensitivity than OC. (4, 5) Results from the largest study of a screening population (n>2,500), the American College of Radiology Imaging Network (ACRIN) 6,664 trial, (6) were recently published and reviewed in a 2009 BCBSA TEC Assessment. (7) This study used 16- to 64-row detector CT scanners, stool-tagging techniques, and minimum training standards for interpreters of the test. The results of this study showed 90% sensitivity of VC for polyps 10 mm or larger and 86% specificity; positive and negative predictive values were 23% and 99%, respectively.

The results of the ACRIN trial may have been dependent on the technical standards required for performance of the test and the training and skill of the interpreters of the test. If these practices can be replicated in the community, then it is likely that improved health outcomes similar to those in the trial can be achieved. Standards of performance and interpretation of VC consistent with those reported in the ACRIN trial will be necessary for VC to be an effective screening test.

A meta-analysis published in 2011 by de Haan et al. (8) of diagnostic characteristics of VC in screening populations showed summary sensitivities and specificities that were similar to prior studies. Estimated sensitivities for polyps or adenomas 10 mm or larger were 83.3% and 97.9%, respectively.

The diagnostic accuracy of VC compared to colonoscopy was assessed in a 2012 study by Zalis et al., using a laxative-free bowel preparation technique for VC. (9) For adenomas 10 mm or larger, the sensitivity of VC was similar but slightly lower than colonoscopy. For smaller adenomas, the sensitivity of VC was lower than colonoscopy.

Conclusions: There is some variability in the diagnostic accuracy of VC in the literature; this is likely due to the improvement in technical performance over time. The most recent studies have reported that diagnostic accuracy for VC is high and in the same range as OC for polyps greater than 10 mm.

VC in patients with contraindications to OC

VC may also be indicated in patients who have contraindications to conventional OC or in patients who have incomplete conventional OC because of colonic obstruction or stenosis. A case series by Yucel and colleagues (10) reported on 42 patients older than 60 years (mean: 71 years; range: 60–87 years) referred for VC because of contraindications to the conventional procedure (n=12) or incomplete colonoscopy (n=30). Contraindications included anticoagulation therapy (n=8), increased anesthesia risk (n=3), or poor tolerance for colonoscopy preparation (n=1). The most common reasons for incomplete colonoscopy included diverticular disease, colonic redundancy, adhesions, and residual colonic content. Optimal distension of the entire colon was achieved in 38 patients (90%), and 39 (93%) of the patients had abnormal findings. Extracolonic findings potentially requiring further evaluation or treatment were observed in 26 patients (62%).

Impact of VC on health outcomes

There is no direct evidence that evaluates the impact of VC on health outcomes compared to OC. Modeling studies, generally done as part of cost-effectiveness analyses, can provide some insights into the health outcome benefits of VC. .

Given the chain of logic and other underlying evidence that supports the practice of accepted colon cancer screening techniques such as OC, a 90% sensitivity of VC for detection of polyps 10 mm or larger is consistent with an improvement in health outcomes. The 86% specificity of VC would result in some false-positive tests, which, in turn, would result in some unnecessary follow-up colonoscopies. However, compared with OC, there are several other types of health outcomes that may differ in terms of convenience, cost, detection of unrelated health problems, and radiation exposure. These are difficult to quantify and are probably small in magnitude compared to the health benefit of identifying and removing cancer precursors.

Conclusions: There are no long-term comparative studies that directly report on outcomes of VC compared to OC. The determination of comparative outcomes of VC and OC complex, due to the differing patterns of follow-up associated with each strategy.

Impact of VC on colon cancer screening adherence

Compliance with recommendations for OC is suboptimal. VC has been proposed as an alternative CRC screening technique that may improve patient compliance, compared to OC. A literature survey of studies which attempt to determine whether the availability of VC would improve population screening rates found a diffuse literature consisting of survey studies, patient satisfaction studies, and focus group studies. It is unclear how such studies provide a sufficient base of evidence to demonstrate that population adherence to colon cancer screening would improve through VC.

Stoop et al published a randomized controlled trial (RCT) in 2012 that evaluated the impact of VC on CRC screening rates. (11) This study was performed in the Netherlands, and members of the general population aged 50-75 years were randomized to an invitation for VC or OC. The VC protocol included a non-cathartic preparation, consisting of iodinated contrast agent given the day before the exam and 1.5 hours before the exam, in conjunction with a low fiber diet. The participation rate in the VC group was 34% (982/2,920), compared to a rate of 22% (1,276/5,924) in the OC group (p<0.0001). The diagnostic yield per patient of advanced polyps was higher in the OC group, at 8.7/100 participants compared to 6.1/100 participants for VC (p=0.02). However, the diagnostic yield of advanced neoplasia per invitee was similar, at 2.1/100 invitees for VC compared to 1.9/100 invitees for OC (p=0.56). These data indicate that the increased participation rates with VC offset the advantages of OC, and that overall outcomes are likely to be similar between the two strategies. It is not known whether the same participation rates would be achieved if VC employed a cathartic preparation, or whether the different preparation regimens affect participation rates.

Conclusions: At least one well-done RCT reports that participation rates are improved with VC compared to OC. The improved screening rate may offset, or even outweigh, any benefit of OC on outcomes. However, the available study used a non-cathartic preparation, and it is not certain that similar screening rates would be achieved with a cathartic preparation.

Practice Guidelines and Position Statements

The 2008 edition of colorectal cancer screening guidelines released jointly by the American Cancer Society (ACS), the American College of Radiology (ACR), and the U.S. Multisociety Task Force on Colorectal Cancer (12) recognizes two types of screening tests: colon cancer prevention and cancer detection. Colon cancer prevention tests detect both early cancer and adenomatous polyps. The cancer prevention options recommended were flexible sigmoidoscopy every 5 years, colonoscopy every 10 years, double-contrast barium enema every 5 years, or VC every 5 years. For cancer detection, three types of fecal screening tests were supported: annual guaiac-based tests, annual fecal immunochemical tests, and stool DNA tests. The ACS endorses colon cancer prevention as the “primary goal of [colorectal cancer] screening” where resources and patient acceptance permit. (12)

In the 2008 clinical guideline statement of the U.S. Preventive Services Task Force (USPSTF) on CRC screening, (13) the evidence for VC was judged to be insufficient to evaluate the benefits and harms. This guideline was based on concerns about potential harms of radiation exposure and potential for harm due to evaluation of extracolonic findings.

Given that much of the evidence supporting CRC screening is indirect, it is not so surprising that consensus groups reviewing the same evidence might come to different conclusions, as have the USPSTF and the ACS regarding VC. Although both groups reviewed the same evidence and similar decision models to reach their conclusions, Pignone and Sox (14) suggest that subtle differences in emphasis may underlie the differing conclusions. The USPSTF is more concerned with the potential unknown effects of radiation exposure and workups for extracolonic findings, taking a more longitudinal perspective. The ACS report concentrates on the capability of VC to detect large polyps in a single screening visit as the principal criterion to determine colon cancer prevention. Thus, the ACS report favors screening technologies with superior single-screening detection characteristics over less sensitive tests that have demonstrated efficacy with repeated screening.

A 2006 statement by ACS and the U.S. Multi-Society Task Force on Colorectal Cancer on colonoscopy surveillance after cancer resection recommended that in patients with obstructing colon cancers, VC with intravenous contrast may be used to detect neoplasms in the proximal colon. (15)

A position statement by the American College of Gastroenterology (ACG) in 2006 (prior to the publication of the ACRIN 6664 trial) also expressed concerns over additional areas of uncertainty such as the radiation risk, interpretation, and management of extracolonic findings, and the cost-effectiveness of VC. (16)

Summary

The available evidence supports the conclusion that the diagnostic accuracy of VC is in the same range as OC, with a moderate to high sensitivity and a high specificity for larger polyps. As a result, screening with VC may provide similar diagnostic results to screening using conventional colonoscopy. The majority of modeling studies report that the overall health outcome benefits of a strategy that uses OC likely exceed the benefits of a strategy using VC. However, these analyses assume equal participation rates in screening between the two strategies. Thus, for use in CRC screening, VC is considered not medically necessary when patients are able to undergo OC.

Virtual Gastroscopy (VG)

Two ECRI Emerging Technology Evidence Reports published in 2011 and a Hotline Response published in May 2012 reported on the utilization of CT gastrography for screening and diagnosis of gastric cancer, CT gastrography for staging a gastric cancer, and virtual endoscopy for imaging the upper gastrointestinal tract. (23, 24, 25) They concluded in reviewing clinical studies using CT to diagnose conditions suggestive of and staging of gastric cancer that the studies reported diagnostic accuracy rates of VG between 32% and 100% for early-stage tumors (EGC) and between 86% and 100% for late-stage (advanced) tumors (AGC). (23) Diagnostic accuracy for EGC could be improved with 3-D CT image analysis. Staging accuracy rates ranged between 64% and 94% for staging of gastric tumors and between 63% and 84% for lymph node staging. VG overstaged a range of 0%-17% of tumor staging and understaged a range of 0%-25%. VG overstaged a range of 0%-25% of lymph node staging and understaged a range of 9%-27%. Only 3 studies reported on metastasis, with a miss rate of roughly 1% overall. One of those studies compared VG to transverse CT and found their performance was the same. ECRI conveyed that when VG was compared to other endoscopic ultrasound and MRI, the conclusion could not be determined due to insufficient information.

Additionally, ECRI determined there were no studies available to answer the following questions (24):

  1. Does using VG for disease staging improve patient outcomes?
  2. How do these outcomes compare to other imaging techniques used to stage gastric cancer?
  3. How does the safety profile of VG compare to other imaging techniques used to stage gastric cancer?
  4. What adverse events are associated with CT use with VG?

ECRI reported on VG used for screening asymptomatic patients for EGC and for diagnosing the conditions of patients with signs and symptoms suggestive of gastric cancer. (24) For the diagnosis of malignancy in patients with gastric ulcers in a single diagnostic stud, VG had a sensitivity of 92.1% (95% confidence interval [CI]: 85.9%-98.3%) and a specificity of 91% (95% CI: 82.9%-100%). Outcomes for conventional optical gastric endoscopy (OE) (without histology) were similar, with a sensitivity of 88.2% (95% CI: 80.8%-95.5%) and specificity of 89.5% (95% CI: 79.5%-99.5%). ECRI cited Chen et al., a retrospective study that concluded the results of VG and conventional OE were comparable but recommended OE be performed in addition to VG to confirm findings. (27) This is a result of biopsies that cannot be collected during the CT and because CT missed one case of cancer that the OE easily recognized. Moreover, the results of a single moderate-quality study are insufficient to support an evidence-based conclusion. Information on the safety profile for VG had not been identified when VG was compared to other diagnostic techniques. As with the earlier discussion on adverse events associated with CT use, no studies were available. Although, in the Chen et al study, it was stated that VG does administer a “substantial dose of ionizing radiation.” (26) As with CT repeated utilization for screening or monitoring, long-term studies are needed to address the sequelae of CT exposure.

Practice Guidelines and Position Statements

There were no practice guidelines or position statements located from professional societies.

Summary

The insufficient evidence supports the conclusion that the utilization of VG, when compared to conventional standard optical gastric endoscopy, requires additional studies, particularly randomized controlled clinical trials. Many of the studies reviewed by ECRI involved small numbers of patients and provided no selection criteria. Additionally, VE has not been studied to the extent that VC has been studied. Therefore, VG is considered experimental, investigational and/or unproven to screen, monitor, evaluate, detect, or follow-up on any type of gastric lesion.

Virtual Uro-Endoscopy (VUE)

As with VG, the numbers of studies are scarce and the numbers of patients within the studies were of small numbers. VUE has been cited as a method to identify a variety of urinary tract conditions. Conventional cystoscopy represents the gold standard for the diagnosis and local management of bladder cancer, which accounts for 90% of the cancer cases in the low urinary tract. (29, 30) Single center study by Prando in 2002 demonstrated a variety of uses for VUE from bladder cancer follow-ups, complimentary or adjunctive use for evaluation of urinary tract abnormalities that were difficult to approach conventionally, to the differential diagnosis of intrinsic versus extrinsic lesions of the renal pelvis and ureter. (31) Despite the success documented by Prando, this was a small case-series and a patient selection criterion was not developed.

Practice Guidelines and Position Statements

There were no practice guidelines or position statements located from professional societies.

Summary

The insufficient evidence supports the conclusion that the utilization of VUE, when compared to the gold standard, conventional cystoscopy, requires additional studies, particularly randomized controlled clinical trials. The numbers of studies regarding the utilization of VUE have been scarce. Thus, VUE is considered experimental, investigational and/or unproven based upon the lack of peer reviewed scientific literature or any additional information that could be located.

Coding

Disclaimer for coding information on Medical Policies

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.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8, 153.9, 211.3, 211.4, V76.51

ICD-10 Codes
C18.0-C18.9, C19, Z12.10-Z12.13,  Z15.09, Z80.0, BD2400Z, BD240ZZ, BD2410Z, BD241ZZ, BD24Y0Z, BD24YZZ, BD24ZZZ 
Procedural Codes: 74261, 74262, 74263, 76497
References

Virtual Colonoscopy (VC) 1-21; Virtual Gastroscopy (VG) 22-26; Virtual Uro-Endoscopy (VUE) 27-31

  1. VC (“Virtual Colonoscopy”) for Colon Cancer Screening. Chicago, Illinois: Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (2004 July) 19(6).
  2. Mulhall, B.P., Veerappan, G.R., et al. Meta-analysis: Computed tomographic colonography. Annals of Internal Medicine (2005 April 19) 142(8):635-50.
  3. Pickhardt, P.J., Choi, R., et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. New England Journal of Medicine (2003 December 4) 349(23):2191-200.
  4. Cotton, P.B., Durkalski, V.L., et al. Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. Journal of the American Medical Association (2004 April 14) 291(14):1713-9.
  5. Rockey, D.C., Paulson, E., et al. Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: perspective comparison. Lancet (2005 January) 365(9456):305-11.
  6. Johnson, C.D., Chen, M.H., et al. Accuracy of VC for detection of large adenomas and cancers. New England Journal of Medicine  (2008 September 18) 359(12):1207-17.
  7. VC ("virtual colonoscopy") for Colon Cancer Screening. Chicago, Illinois: Blue Cross and Blue Shield Association – Technology Evaluation Center Assessment Program (2009) 24 (1).
  8. de Haan MC, van Gelder RE, Graser A et al. Diagnostic value of CT-colonography as compared to colonoscopy in an asymptomatic screening population: a meta-analysis. Eur Radiol 2011; 21(8):1747-63.
  9. Zalis ME, Blake MA, Cai W et al. Diagnostic accuracy of laxative-free computed tomographic colonography for detection of adenomatous polyps in asymptomatic adults: a prospective evaluation. Ann Intern Med 2012; 156(10):692-702.
  10. Yucel, C., Lev-Toaff, A.S., et al. VC for incomplete or contraindicated optical colonoscopy in older patients. American Journal of Roentgenology (2008 January) 190(1):145-50.
  11. Stoop EM, de Haan MC, de Wijkerslooth TR et al. Participation and yield of colonoscopy versus non-cathartic VC in population-based screening for colorectal cancer: a randomized controlled trial. Lancet Oncol 2012; 13(1):55-64.
  12. Levin, B., Lieberman, D.A., 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 U.S. Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. A Cancer Journal for Clinicians (2008 May-June) 58(3):130-60.
  13. Anonymous. Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine (2008 November 4) 149(9):627-37.
  14. Pignone M, Sox HC. Screening guidelines for colorectal cancer: a twice-told tale. Ann Intern Med 2008; 149(9):680-2.
  15. Rex, D.K., Kahi, C.J., et al. Guidelines for colonoscopy surveillance after cancer resection: a consensus update by the American Cancer Society and U.S. Multi-Society Task Force on Colorectal Cancer. A Cancer Journal for Clinicians (2006 May-June) 56(3):160-7.
  16. Rex DK, Lieberman D. ACG colorectal cancer prevention action plan: update on CT-colonography. Am J Gastroenterol 2006; 101(7):1410-3.
  17. NIH – Bitter, I., Aslam, B., et al. Candidate Determination for Computer Aided Detection of Colon Polyps. National Institutes of Health, Program Paper from The International Society of Optical Engineering, Medical Imaging (2005) Volume 5746: 804-9. http://www.//cc.nih.gov .
  18. NIH News – Computer-Aided Polyp Detection Software in Combination with Virtual Colonoscopy is as Effective as Traditional Optical Colonoscopy. National Institute of Health Clinical Center (2005 December 1). http://www.nih.gov .
  19. AHRQ – U.S. Preventive Services Task Force Recommendation, Screening for Colorectal Cancer, Clinical Summary, AHRQ Publication No. 08-05124-EF-4. Agency for Healthcare Research and Quality (2008 October). Available at http://www.ahrq.gov (accessed on – 2009 March 26).
  20. ECRI Institute. Computed tomographic colonography for screening and diagnosing colorectal cancer. Plymouth Meeting (PA): ECRI Institute; 2012 May. 11 p. (Hotline Response).
  21. Virtual Colonoscopy/CT Colonography. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2013 May) Radiology: 6.01.32.
  22. Shen, Y., Kang, H.K., et al. Evaluation of early gastric cancer at multidetector CT with multiplanar reformation and virtual endoscopy. Radiographics (2011 January) 31: 189-99. Available at http://radiographics.rsna.org accessed on 2013 October 16.
  23. ECRI Institute. CT gastrography for staging of gastric cancer. Plymouth Meeting (PA); ECRI Institute; 2011 Mar. 24 p. (Emerging Technology Evidence Report).
  24. ECRI Institute. CT gastrography for screening and diagnosis of gastric cancer. Plymouth Meeting (PA); ECRI Institute; 2011 Jan. 19 p. (Emerging Technology Evidence Report).
  25. ECRI Institute. Virtual endoscopy for imaging the upper gastrointestinal tract. Plymouth Meeting (PA); ECRI Institute; 2012 May 8 p. (Hotline Response).
  26. Chen, C.Y., Kuo, Y.T., et al. Differentiation between malignant and benign gastric ulcers: CT virtual gastroscopy versus optical gastroendoscopy. Radiology (2009 August) 252(2):410-7.
  27. Zantl, N., Beer, A., et al. Virtual endoscopy of the urinary tract. Urologe A. (2002 November) 41(6):552-8.
  28. Kagadis, G.C., Siablis, D., et al. Virtual endoscopy of the urinary tract. (2006 January) 8(1):31-8.
  29. Lammle, M., Beer, A., et al. Reliability of MR imaging-based virtual cystoscopy in the diagnosis of cancer of the urinary bladder. American Journal of Roentgenology (2002 June) 178(6):1483-8.
  30. Panebianco, V., Sciarra, A., et al. Bladder carcinoma: MDCT cystography and virtual cystoscopy. Abdominal Imaging (2010 June) 35(3):257-64.
  31. Prando, A. CT-virtual endoscopy of the urinary tract. International Brazilian Journal of Urology (2002 July-August) 28(4):317-22.
History
June 2012  Policy updated with literature search. References 8, 19, 20, 21 added. No change to policy statement; policy language amended to reflect revised language for not medically necessary.
September 2013 Policy formatting and language revised.  Policy statement unchanged.  Title changed from "Virtual Colonoscopy/CT Colonography" to "Virtual Colonoscopy (VC), Computed Tomography Colonography (CTC)".  Removed codes 0066T and 0067T.
March 2014 Document updated with literature review. Coverage unchanged for virtual colonoscopy (VC) services. Rationale completely revised for VC. The following virtual endoscopy methods were added as experimental, investigational and/or unproven: 1.) virtual gastroscopy (VG); and, 2.) virtual uro-endoscopy (VUE). CPT/HCPCS codes updated. Title changed from Virtual Colonoscopy (VC), Computed Tomography Colonography (CTC).
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Virtual Endoscopy, Including Virtual Colonoscopy