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Medical Policy Revision: Colorectal Cancer Screening

Effective May 2, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for colorectal cancer screening.

Our medical policy, Colorectal Cancer Screening (formerly titled Flexible Colonoscopy and Other Colorectal Cancer Screening Procedures) outlines the tests that find polyps and/or cancer that may be considered medically necessary or investigational based on the patient’s age, the patient’s risk level for developing colorectal cancer and the type of plan in which the patient is enrolled.

According to the guidelines of this policy, certain types of colorectal cancer screening tests may be considered investigational based on whether the health insurance plan in which a patient is enrolled is subject to the guidelines of the New Jersey Colorectal Cancer Screening mandate and/or the recommendations of the U.S. Preventive Services Task Force (USPSTF).

We encourage you to review this revised policy in our online Medical Policy Manual.

Based on the guidelines of our medical policy, Colorectal Cancer Screening, and the type of coverage in which a particular patient is enrolled, we will consider claims that include CPT® code 81528 and/or HCPCS code G0464, as noted below.

For members enrolled in insured health plans that are subject to the New Jersey Colorectal Cancer Screening mandate and those members enrolled in coverage offered through “grandfathered” self-insured/Administrative Services Only (ASO) employer groups that have opted to adopt the New Jersey Colorectal Cancer Screening mandate.

  • Claims for services provided to patients 50 years of age and over on and after May 2, 2016 that include CPT code 81528 and/or HCPCS code G0464 may, based on the diagnosis code(s) included, pend while information to determine medical appropriateness is requested and reviewed.
  • CPT code 81528 and/or HCPCS code G0464 submitted on claims for services provided to patients 50 years of age and over on and after May 2, 2016 may be denied as investigational services based on the submitted diagnosis code(s).
  • CPT code 81528 and/or HCPCS code G0464 submitted on claims for services provided to patients under 50 years of age on and after May 2, 2016 will be denied as investigational services regardless of the submitted diagnosis code(s).

For members enrolled in health plans that are NOT subject to the New Jersey Colorectal Cancer Screening mandate, including: members enrolled in coverage offered through “grandfathered” self-insured/ASO employer groups that have opted NOT to adopt this mandate; members enrolled in coverage offered through “grandfathered” self-insured/ASO employer groups that have opted to follow the U.S. Preventive Services Task Force (USPSTF) recommendations for colorectal cancer screening, or; members enrolled in coverage offered through “non-grandfathered” self-insured/ASO employer groups.

  • CPT code 81528 and/or HCPCS code G0464 submitted on claims for services provided on and after May 2, 2016 will be denied as investigational services regardless of the submitted diagnosis code(s).

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after May 2, 2016.

Published on: February 2, 2016, 15:00 p.m. ET
Last updated on: November 24, 2020, 23:50 p.m. ET