Description 

• It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted. 
• Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.
• The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.

Purpose
Computed tomographic colonography (CTC), also referred to as virtual colonoscopy, is a minimally invasive structural examination of the colon and rectum to evaluate for colorectal polyps or neoplasms.

Policy  
INDICATIONS ^(1,2)
For diagnostic evaluation
Symptomatic patients when conventional colonoscopy is contraindicated or could not be completed and ONE of the following: 

• Patient had failed or incomplete colonoscopy⁽¹⁾ 
• Patient has an obstructive colorectal cancer
• When colonoscopy is medically contraindicated or not possible (e.g., patient is unable to undergo sedation or has medical conditions such as a recent myocardial infarction, recent colonic surgery, a bleeding disorder, or severe lung and/or heart disease)⁽¹⁾

Follow-Up Studies

• For a 3-year follow-up when 1-2 polyps that are 6-9 mm in diameter detected at CTC if patient does not undergo polypectomy (or is unwilling or unable to undergo colonoscopy)⁽²⁾

NOTE: CT (Virtual) Colonoscopy is not indicated in routine follow-up of inflammatory bowel disease, hereditary polyposis or non-polyposis cancer syndromes, evaluation of anal disease, or the pregnant or potentially pregnant patient.⁽¹⁾

Rationale
SUMMARY OF EVIDENCE
ACR-SABI SAR Practice Parameter for the Performance of Computed Tomography (CT) 
Colonography in Adults⁽¹⁾

Study Design: This document outlines the practice parameters for the performance of CT colonography in adults. It includes guidelines for screening, surveillance, and diagnostic examinations. 

Target Population: The target population includes adults at average or moderate risk for developing colorectal carcinoma. This includes individuals with a preceding positive stool-based test or positive family history. 

Key Factors:
Indications: CT colonography is indicated for screening individuals at average or moderate risk, surveillance of patients with a history of colonic neoplasm, and diagnostic examination in symptomatic patients. 

Contraindications: Conditions requiring caution include symptomatic acute colitis, recent colorectal surgery, and known or suspected colonic perforation. 

Preparation: Colon preparation involves a combination of cleansing laxatives, tagging agents, and iodinated contrast material. 

Technique: The examination technique includes mechanical insufflation using carbon dioxide, imaging in multiple positions, and use of low-dose, non-enhanced CT techniques. 

Quality Control: Quality control measures include ensuring complete anatomic coverage of the colon and rectum, adequate colon cleansing and distention, and tracking radiation dose.

NCCN Clinical Practice Guidelines for Colorectal Cancer Screening V1.2024⁽²⁾
Study Design
The document outlines the practice parameters for the performance of CT colonography in adults. It includes guidelines for screening, surveillance, and  diagnostic examinations.

Target Population
The target population includes adults at average or moderate risk for developing colorectal carcinoma. This includes individuals with a preceding positive stool-based test or positive family history.

Key Factors
Indications: CT colonography is indicated for screening individuals at average or moderate risk, surveillance of patients with a history of colonic neoplasm, and diagnostic examination in symptomatic patients.

Contraindications: Conditions requiring caution include symptomatic acute colitis, recent colorectal surgery, and known or suspected colonic perforation.
Preparation: Colon preparation involves a combination of cleansing laxatives, tagging agents, and iodinated contrast material.

Technique: The examination technique includes mechanical insufflation using carbon dioxide, imaging in multiple positions, and use of low-dose, non-enhanced CT techniques.

Quality Control: Quality control measures include ensuring complete anatomic coverage of the colon and rectum, adequate colon cleansing and distention, and tracking radiation dose.

ANALYSIS OF EVIDENCE
Shared Conclusions^(1,2)
Both documents emphasize the importance of CT colonography in colorectal cancer screening, particularly for individuals at average or moderate risk. They agree that CT colonography is a valuable tool for detecting colorectal neoplasia and improving patient outcomes.

References 

1. American College of Radiology, Society for Advanced Body Imaging, Society for Abdominal Radiology. ACR-SABI-SAR PRACTICE PARAMETER FOR THE PERFORMANCE OF COMPUTED TOMOGRAPHY (CT) COLONOGRAPHY IN ADULTS.; 2024.
2. Referenced with permission from the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Colorectal Cancer Screening Version 1.2024 © National Comprehensive Cancer Network, Inc. 2025. All rights reserved. To view the most recent and complete version of the guideline, go online to NCCN.org.
3. Rhode Island General Laws. The Maryellen Goodwin Colorectal Cancer Screening Act. RI Gen L 27-18-58; 2021. Accessed February 16, 2025. https://law.justia.com/codes/rhode-island/title-27/chapter-27-18/section-27-18-58

Coding Section

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.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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