Recently, the American Cancer Society (ACS) updated its guidelines for colorectal cancer (CRC) screening for average-risk-level adults. The ACS now recommends that adults ages 45 years and older with an average-risk level of CRC undergo regular screening with either a high?sensitivity stool?based test or a structural (visual) examination. Earlier guidelines recommended that CRC screening for average-risk-level patients begin at age 50. The U.S. Preventive Services Task Force (USPSTF) continues to recommend colorectal cancer screening for average-risk individuals starting at age 50.

Colorectal cancer screening with member cost-sharing

As of July 1, 2018, AmeriHealth covers CRC screening and related services for average-risk-level AmeriHealth Pennsylvania members beginning at age 45 with applicable member cost-sharing (i.e., copayments, coinsurance, and deductibles).

According to the ACS, patients at average-risk level are those:

• without a history of adenomatous polyps or CRC and are not at increased risk for CRC due to a family history of CRC;
• who have no documentation of a confirmed or suspected hereditary CRC syndrome (such as familial adenomatous polyposis or Lynch syndrome);
• who have no personal history of abdominal or pelvic radiation for a previous cancer; or a personal history of inflammatory bowel disease.

The ACS recommends CRC screening for individuals at average-risk level, increased-risk level, and high-risk level. Appropriate cost-sharing will continue to apply for CRC screening for increased-risk or high-risk-level individuals. For the factors that determine CRC risk level, refer to the Colorectal Cancer Screening policy mentioned below.

Colorectal cancer screening without member cost-sharing

AmeriHealth cost-sharing requirements are consistent with the requirements of the Affordable Care Act by covering certain CRC screening tests and related services without member cost-sharing when using an in-network provider.*

For AmeriHealth members enrolled in a commercial plan, when the CRC screening tests identified above are billed, they will be processed as a preventive service based on the frequency and age recommendations described by the USPSTF and outlined in Attachment A of the Preventive Care Services policy referenced below.

It is important to note that CRC screening tests that are not included in the USPSTF recommendations will be subject to medical necessity review and member cost-sharing, based on the terms of the member?s benefit plan.

For more information

For detailed information, refer to the following commercial medical policies:

• #00.06.02v: Preventive Care Services
• #11.03.12o: Colorectal Cancer Screening

To view these policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, then select Commercial and type the policy name or number in the Search field.

*Small group (1-50) and consumer commercial plans include a Preventive Plus feature that requires members to see a Preventive Plus provider and meet the Preventive criteria for colonoscopy screenings to be covered with $0 cost-sharing; cost-sharing will apply when members have colonoscopy screenings performed by in-network non-Preventive Plus providers. Small group and consumer commercial members who live outside of our five-county service area (i.e., Bucks, Chester, Delaware, Montgomery, and Philadelphia counties) and contiguous counties (i.e., counties that surround the AmeriHealth five-county service area) may obtain a Preventive colonoscopy screening from any in-network provider at $0 cost-sharing.