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Independence is consistent with the requirements of
the Affordable Care Act by covering certain colorectal
cancer screening tests without member cost-sharing
(i.e., copayments, coinsurance, and deductibles)
when using an in-network provider.* Currently,
the United States Preventive Services Task Force
(USPSTF) recommends screening for colorectal
cancer in adults beginning at age 50 and continuing
until age 75 using one of the following:
- fecal occult blood testing
- highly sensitive fecal immunochemical testing (FIT)
- CT colonography
- stool DNA testing (alone or combined with FIT)
- flexible sigmoidoscopy
- colonoscopy
- barium enema
Reminder: $0 cost-sharing for related
screening services
No member cost-sharing is required for the following
services when associated with a Preventive colorectal
cancer screening procedure, when the criteria outlined
in the Preventive Care Services policy are met:
- prescription bowel preparation medication for flexible
sigmoidoscopy, colonoscopy, or CT colonography;
- pre-procedure consultation visit for flexible
sigmoidoscopy, colonoscopy, or CT colonography;
- anesthesia associated with flexible sigmoidoscopy or
colonoscopy;
- pathology associated with flexible sigmoidoscopy or
colonoscopy.
For members enrolled in a commercial plan, when the colorectal cancer
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 Medical Policy #00.06.02s: Preventive
Care Services. This policy was posted
as a Notification on November 1, 2016, and will become effective on January 1,
2017.
Please note that colorectal cancer screening tests that are
not included in the USPSTF recommendations will be
subject to medical necessity and member cost-sharing, based on the terms of the
member?s benefit plan. Refer to
Medical Policy #11.03.12m: Colorectal Cancer Screening for more information.
This policy is currently posted as a
Notification and will become effective on January 1, 2017.
Additionally, when a medically necessary esophagogastroduodenoscopy (EGD) is
performed on the same day as a
Preventive colorectal cancer screening test (e.g., colonoscopy), it is subject
to applicable member cost-sharing.
To access these policies, visit our Medical Policy Portal and select Accept and Go
to
Medical Policy Online. Then select Commercial and type the policy
name or number in the Search field.
New billing requirement
Beginning January 1, 2017, when billing for a colonoscopy or flexible
sigmoidoscopy that converts from a screening
to a diagnostic service, a PT modifier must be appended to the appropriate
diagnostic CPT® code to indicate the
service turned into a diagnostic procedure.
*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 Independence five-county service area) may obtain a
Preventive colonoscopy screening from any in-network provider at
$0 cost-sharing.
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