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Medical Policy Update: Colorectal Cancer Screening

Effective February 25, 2020, Horizon BCBSNJ will change the way we consider certain professional claims based on updates to our medical policy, Colorectal Cancer Screening.

We encourage you to access our Medical Policy Manual to review the guidelines of our medical policy, Colorectal Cancer Screening.


Claims for services provided on and after February 25, 2020 to patients enrolled in Horizon BCBSNJ Medicare Advantage (MA) plans will be processed as noted below.

  • Regardless of the submitted diagnosis code(s), HCPCS code G0105 included on claims for services provided on and after February 25, 2020 will be denied as not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, based on a national coverage determination or local coverage determination.

We are decreasing the age criteria pertinent to our consideration of CPT®code 81528 for patients enrolled in Horizon BCBSNJ commercial and Administrative Services Only (ASO) plans.

This update will result in an expansion in the access to the services represented by this CPT code to patients between age 45 and 49 years. Claims for services provided on and after February 25, 2020 to this population of patients will be processed as noted below.

  • Based on the submitted diagnosis code(s), the services represented by CPT code 81528 included on claims for services provided to patients age 45 years and older may be denied as experimental/investigational non-covered services.
  • Based on the submitted diagnosis code(s), information may be requested to help us determine the medical appropriateness of the services represented by CPT code 81528 included on claims for services provided to patients age 45 years and older. Following our review of medical record information, the services represented by CPT code 81528 may be denied as experimental/investigational non-covered services.
  • Regardless of the submitted diagnosis code(s), CPT code 81528 included on claims for services provided to patients under age 45 years will be denied as experimental/investigational non-covered services.

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 on and after February 25, 2020.

CPT® is a registered mark of the American Medical Association.

Published on: January 24, 2020, 10:20 a.m. ET
Last updated on: January 24, 2020, 12:33 p.m. ET