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 to 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.

As of July 1, 2018, AmeriHealth New Jersey covers CRC screening and related services for average-risk-level patients beginning at age 45 without 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. For the factors that determine CRC risk level, refer to the Colorectal Cancer Screening policy mentioned below.

AmeriHealth New Jersey 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.

In compliance with New Jersey mandates, for AmeriHealth New Jersey members enrolled in a commercial plan, when the CRC screening tests identified above are billed based on the recommendations described by the ACS or USPSTF and outlined in Attachment D of the Preventive Care Services policy referenced below, they will be processed as a preventive service.

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.