Selina Posted Tue 29th of October, 2019 10:29:38 AM
Good Morning, Are you able to help with this question from one of our offices: If patient had a colonoscopy 3/2009 and had polyps
Next colonoscopy is 10/2019 – does the screening colonoscopy “reset” since it’s been 10 years and can be a screening or is it personal history colon polyps?
Insurance is Aetna
SuperCoder Answered Wed 30th of October, 2019 04:16:41 AM
A colonoscopy is one of several screening tests for colorectal cancer.
For Routine Screening, Aetna considers any of the following colorectal cancer screening tests medically necessary preventive services for average-risk members aged 45 years and older when these tests are recommended by their physician:
- Annual immunohistochemical or guaiac-based FOBT; or
- Colonoscopy (considered medically necessary every 10 years for persons at average risk); or
- CT Colonography (virtual colonoscopy) (considered medically necessary every 5 years)
- Double contrast barium enema (DCBE) (considered medically necessary every 5 years for persons at average risk); or
- Sigmoidoscopy (considered medically necessary every 5 years for persons at average risk)
- Sigmoidoscopy (every five years) with annual immunohistochemical or guaiac-based fecal occult blood testing (FOBT); or
- Stool DNA (FIT-DNA, Cologuard) (considered medically necessary every 3 years).
Routine colorectal cancer screening for members 85 years of age or older is considered not medically necessary unless life expectancy is greater than or equal to 10 years.
For High-Risk Testing, Aetna considers colorectal cancer testing with sigmoidoscopy, DCBE, or colonoscopy as frequently as every 2 years medically necessary for members with any of the following risk factors for colorectal cancer:
- A first-degree relative (sibling, parent, child) who has had colorectal cancer or adenomatous polyps (screening is considered medically necessary beginning at age 40 years, or 10 years younger than the earliest diagnosis in their family, whichever comes first); or
- Family history of familial adenomatous polyposis (screening is considered medically necessary beginning at puberty); or
- Family history of hereditary non-polyposis colorectal cancer (HNPCC) (screening is considered medically necessary beginning at age 20 years); or
- Family history of MYH-associated polyposis in siblings (screening is considered medically necessary beginning at age 25 years); or
- Diagnosis of Cowden syndrome (screening is considered medically necessary beginning at age 35 years).
Aetna considers annual FOBT, alone or in conjunction with sigmoidoscopy, medically necessary for testing of members with any of the above risk factors for colorectal cancer.
CRC screening refers to the process of looking for cancer in people who have no symptoms of the disease. Screening tests may identify cancers at an early and potentially more treatable stage. Testing may also detect precancerous abnormal growths (eg, polyps) which can be removed before becoming malignant.
The American Cancer Society recommends the following testing options for the early detection of adenomatous polyps and cancer for asymptomatic adults aged 50 years and older:
Tests that detect adenomatous polyps and cancer
- Colonoscopy every 10 years; or
- Computed tomographic (CT) colonography every 5 years; or
- Double-contrast barium enema (DCBE) every 5 years; or
- Flexible sigmoidoscopy every 5 years.
Hence, you can perform the screening colonoscopy with diagnosis of personal history of colon polyps.
Hope this helps!