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concluded that the collective evidence suggests that CTC is an accurate tool for detecting clinically important colorectal polyps (i.e., those that are greater than or equal to 10 mm in diameter). The sensitivity and specificity of CTC, pooled across the 14 studies, were high for polyps greater than or equal to 10 mm. However, this analysis had several limitations: small numbers of patients enrolled in each study, inherent publication bias, possible verification bias, and heterogeneity of studies (which was not accounted for in the analysis). Halligan et al. also concluded that CTC was sufficiently sensitive and specific for the detection of large (greater than or equal to 10 mm) and medium-sized (6-9 mm) polyps, and especially sensitive in the detection of symptomatic cancer.
In contrast, the authors of the largest meta-analysis, Mulhall et al., reported that while CTC is highly specific, especially for polyps greater than or equal to 6 mm, the reported sensitivities varied widely, even for larger polyps. Patient and scanner characteristics (such as collimation, scanner type, and mode of imaging) accounted for some, but not all, of this variability. The authors comment that this heterogeneity raises concerns about the consistency of performance of the test and about technical variability and until these issues are resolved, they cannot recommend CTC for generalized screening. The authors also noted that colonoscopy is an imperfect reference standard since it may miss 10% of small polyps, less than or equal to 10% of large polyps, and less than or equal to 5% of colorectal cancers and, even with segmental unblinding or optimized colonoscopy, some lesions may be missed. Finally, only three of the studies in this analysis were designed to evaluate a true screening population, or individuals who are at average risk for CTC.
Another recent, large study assessed the comparative accuracy of three imaging tests (ACBE, CTC, and colonoscopy), and reported negative results. Rockey et al. reported that colonoscopy was significantly more sensitive than either ACBE or CTC in 614 patients at high risk for colon neoplasia. While the specificity of ACBE and CTC for lesions greater than or equal to 10 mm were high, it was significantly higher for colonoscopy than either of the other two tests. The remainder Computed Tomographic Colonography - Commercial Medical Management Guideline of the individual studies reported positive results.
Summers et al. compared the sensitivity of CTC to optical colonoscopy for detection of adenomatous colonic polyps in 1186 screening patients at 3 medical centers (Summers, 2005). The data were randomized into separate training (n=394) and test (n=792) sets for analysis by a computer-aided polyp detection (CAD) program. For the test set, per-polyp and per-patient sensitivities for CAD were both 89.3% for detecting retrospectively identifiable adenomatous polyps at least 1 cm in size. The false-positive rate was 2.1 false polyps per patient. Both carcinomas were detected by CAD at a falsepositive rate of 0.7 per patient; only 1 of 2 was detected by optical colonoscopy before segmental unblinding. At both 8mm and 10-mm adenoma size thresholds, the per-patient sensitivities of CAD were not significantly different from those of optical colonoscopy before segmental unblinding. The investigators concluded the per-patient sensitivity of CAD in an asymptomatic screening population is comparable to that of optical colonoscopy for adenomas greater than or equal to 8 mm and is generalizable to new CTC data.
Crohn's disease In a comparative study of 16 patients by Biancone et al., the findings from virtual colonoscopy (VC) were compared to conventional colonoscopy (CC) for assessing postoperative recurrence of Crohn's disease (Biancone, 2003).
Conventional colonoscopy showed perianastomotic recurrence in 15 of 16 patients while virtual colonoscopy detected 11 of the 15 patients. Conventional colonoscopy identified stenosis in 8 of the 16 while virtual colonoscopy detected stenosis in 7 of the 16 patients; therefore, there was a false-negative reading in 1 of the 16 patients. The authors therefore concluded that although the widespread use of virtual colonoscopy in Crohn's disease is currently not indicated because of possible false-negative findings, this technique may represent an alternative to conventional colonoscopy in noncompliant postsurgical patients with a rigid stenosis not allowing passage of the endoscope.
Diverticulitis In a prospective study by Hjern et al., 50 patients diagnosed with diverticulitis were assessed to determine whether computed tomography colonography (CTC) is a viable alternative to colonoscopy (Hjern, 2007). All 50 patients underwent CTC immediately followed by conventional colonoscopy. The results were blinded to the examiners.
Diverticular disease was found in 48 of the 50 (96%) patients utilizing CTC and in 45 of 50 (90%) patients with conventional colonoscopy. These results indicate that CTC can provide at least the same level of accuracy as conventional colonoscopy. The authors conclude that CTC appears to have a better diagnostic potential for imaging of diverticular disease-specific findings when compared with colonoscopy, and is a reasonable alternative in follow-up of patients with symptomatic diverticular disease. The study design, however, did require that the CTC be completed prior to conventional colonoscopy which may have introduced a biased response favoring CTC. In addition, residual gas from CTC may have contributed to greater discomfort during the subsequent colonoscopy. Further studies are needed to determine the efficacy of computed tomographic colonography as a follow-up diagnostic tool for diverticulitis.
Although CTC involves exposure to x-rays and may cause minor complications such as discomfort, bloating, cramping or nausea, it is considered a reasonably safe procedure. The studies selected for detailed review did not report any major adverse events as a consequence of CTC. Definitive patient selection criteria have not been established for CTC as a screening test for colorectal cancer. However, there is sufficient evidence to support the use of CTC as a diagnostic tool for symptomatic patients who are unable to undergo a complete colonoscopy, such as the elderly, individuals with an obstructive tumor, and others who may have a contraindication to the procedure.
Professional Societies American Cancer Society (ACS): In 2008, ACS worked jointly with both the US Multi-Society Task Force and the American College of Radiology to publish colorectal cancer guidelines (Levin, 2008). Based on their review, the task force concluded that screening of average-risk adults with CTC should begin at age 50 years with repeat exams every 5 years if the initial CTC is negative for significant polyps. However, if current studies detect polyps 6 mm or greater, colonoscopy should be offered. Additionally, CTC surveillance could be offered to those patients who would benefit
Computed Tomographic Colonography - Commercial Medical Management Guideline
from screening but either decline colonoscopy or who are not good candidates for colonoscopy for one or more reasons.
If colonoscopy is contraindicated because the patient is not likely to benefit from screening due to life-limiting comorbidity, then neither CTC nor any other CRC screening test would be appropriate.
American Gastroenterological Association (AGA): AGA recommends that the test be performed once every 5 years for average risk individuals and who do not have any signs or symptoms. It is recommended that patients at higher risk for colorectal cancer, including those with a family history or a personal history of polyps or colon cancer should talk to their gastroenterologist about scheduling a colonoscopy since patients with these features are more likely have colon polyps that will require a colonoscopy to remove them. (AGA, 2008) Additional Medical Products GE Advantage Windows Review Workstation, HiSpeed Advantage II, CT-9800, Picker MR Workstations, PQ-5000 CT System, VoxelView, Somatom Plus 4 CT Scanner Additional Search Terms polyposis References and Resources Resources American Cancer Society (ACS) [website]. Study Calls Virtual Colonoscopy Most Cost-Effective Colon Cancer
Screening Test. April 23, 2007. Available at:
http://www.cancer.org/docroot/MED/content/MED_2_1x_Study_Calls_Virtual_Colonoscopy_Most_CostEffective_Colon_Cancer_Screening_Test.asp. Accessed March 19, 2009.
American College of Gastroenterology (ACG) [website]. Patient Information. Colorectal Cancer Screening. 2005.
Available at: http://www.acg.gi.org/patients/gihealth/colon.asp. Accessed March 19, 2009.
American College of Radiology (ACR) [website]. ACR Practice Guideline for the Performance of Computed
Tomography (CT) Colonography in Adults. October 1, 2005a. Available at:
http://www.acr.org/s_acr/bin.asp?TrackID=&SID=1&DID=22490&CID=547&VID=2&DOC=File.PDF. Accessed March 19, 2009.
American Gastroenterological Association (AGA). What is CT Colonography. September 2008. Available at:
http://www.gastro.org/wmspage.cfm?parm1=5833. Accessed March 19, 2009.
Biancone L, Fiori R, Tosti C, Marinetti A, Catarinacci M, De Nigris F, Simonetti G, Pallone F. Virtual colonoscopy compared with conventional colonoscopy for stricturing postoperative recurrence in Crohn's disease. Inflammatory Bowel Diseases. 9(6):343-50, 2003 Nov.
Cotton PB, Durkalski VL, Pineau BC, et al. Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA. 2004;291(14):1713-1719.
ECRI. CT colonography for colorectal cancer detection. Target database. February, 2000. Content current as of October 2007.
Fenlon HM, Ferrucci JT. First International Symposium on Virtual Colonoscopy. AJR Am J Roentgenol. 1999;173:565Computed Tomographic Colonography - Commercial Medical Management Guideline Halligan S, Altman DG, Taylor SA, et al. CT colonography in the detection of colorectal polyps and cancer: systematic review, meta-analysis, and proposed minimum data set for study level reporting. Radiology. 2005;237(3):893-904.
Hayes Inc. Computed Tomographic Colonography (Virtual Colonoscopy). January 14, 2006. Updated search January 2007.
Hjern F, Jonas E, Holmstrom B, Josephson T, Mellgren A, Johansson C. CT colonography versus colonoscopy in the follow-up of patients after diverticulitis - a prospective, comparative study. Clinical Radiology. 62(7):645-50, 2007 Jul.
Hur C, Chung DC, Schoen RE, Gazelle GS. The management of small polyps found by virtual colonoscopy: results of a decision analysis. Clinical Gastroenterology & Hepatology. 5(2):237-44, 2007 Feb.
Iannaccone R, Laghi A, Catalano C, et al. Detection of colorectal lesions: lower-dose multi-detector row helical CT colonography compared with conventional colonoscopy. Radiology. 2003;229(3):775-81.
Iannaccone R, Laghi A, Catalano C, et al. Computed tomographic colonography without cathartic preparation for the detection of colorectal polyps. Gastroenterology. 2004;127(5):1300-1311.
Johnson CD, Harmsen WS, Wilson LA, et al. Prospective blinded evaluation of computed tomographic colonography for screen detection of colorectal polyps. Gastroenterology. 2003;125(2):311-319.
Kim DH, Pickhardt PJ, Taylor AJ, et al. CT Colonography versus Colonoscopy for the Detection of Advanced Neoplasia.
N Engl J Med. 2007 Oct 4;357(14):1403-12.
Mulhall BP, Veerappan GR, Jackson JL. Meta-analysis: computed tomographic colonography. Ann Intern Med. 2005;
Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med. 2003;349(23):2191-2200.
Rockey DC, Paulson E, Niedzwiecki D, et al. Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison. Lancet. 2005;365(9456):305-311.
Sosna J, Morrin MM, Kruskal JB, et al. CT colonography of colorectal polyps: a metaanalysis. AJR Am J Roentgenol.
Summers RM, Yao J, Pickhardt PJ, et al. Computed tomographic virtual colonoscopy computer-aided polyp detection in a screening population. Gastroenterology. 2005 Dec;129(6):1832-44.
Van Gelder RE, Nio CY, Florie J, et al. Computed tomographic colonography compared with colonoscopy in patients at increased risk for colorectal cancer. Gastroenterology. 2004b;127(1):41-48.
History/Updates Policy update. Policy 2008T0320F archived.
4/24/2009 Policy updated and renamed. CMS and coding updated. Policy 2007T0320E archived.
9/2/2008 Policy Update. CMS and coding updated. Policy 2006T0320D archived.
11/1/2007 Computed Tomographic Colonography - Commercial Medical Management Guideline Coding reviewed and current as of this date 4/5/2007 Revised to proven in some circumstances. CMS updated. Policy 2004T0320C archived.
6/15/2006 CPT codes 0066T, 0067T added to Coding Section per direction from the Reimbursement Medical Policy 7/30/2004 Operations Manager Clarified Medicare wording from "Same as Commercial" (noncovered) to [noncovered by Medicare]; SSA 5/7/2004 section 1862(a)(7).
CPT code 76497 added to Coding Section per direction from the Reimbursement Medical Policy Operations 2/16/2004 Manager.
Yearly update. Revisions/additions in multiple sections.
1/15/2004 Policy Reformatted including Coverage and Clinical Recommendations sections 2/22/2002 Coding The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only.
Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.
0066T Computed tomograhicÿcolonography (ie, virtualÿcolonoscopy); screening 0067T CT colonography (ie, virtual colonoscopy): diagnostic 76497 Unlisted computed tomography procedure (eg, diagnostic, interventional)
Proven Diagnosis Codes: