Coverage Criteria: Computed Tomography Colonography

Posted: February 22, 2016

Effective for dates of service on or after November 1, 2008, authorization is required for Computed Tomography (CT) Colonography. MHCP will approve these procedures for screening and diagnosis per the criteria below in cases of incomplete or contraindicated optical colonoscopy. Screening scans may occur every five years. Scanners that are 64-slice (or greater) must be used in all cases.

Approved indications are:

· Coagulopathy

· Anticoagulation (optical colonoscopy contraindicated due to increased patient risk with discontinuation of anticoagulant medication) (Anticoagulation is defined by an INR of 1.5 or greater)

· Incomplete optical colonoscopy of the entire colon due to:

· Obstructing neoplasm

· Spasm

· Redundant colon

· Scarring or altered anatomy from previous surgery

· Stricture or extrinsic compression