Comparison of Draft and Final CT Colonography Local Coverage Determinations (LCDs)

Dec 22, 2005

Contractor Name/Link to Policy	State(s)	Status of LCD	Indications of Coverage
Regence BCBS of Utah	UT	Final	Indicated when a fiberoptic colonoscopy of entire colon is incomplete due to an inability to pass the colonoscope proximally. CT colonography may also be medically reasonable and necessary for those patients in whom a standard colonoscopy is contraindicated.
First Coast Service Options (FCSO)	CT, FL	Draft	Indicated when a fiberoptic colonoscopy of the entire colon is incomplete due to an inability to pass the colonoscope proximally.
Noridian Administrative Services	AK, AZ, CO, HI, IA, ND, NV, OR, SD, WA, WY	Final	Indicated only in those patients in whom an instrument colonoscopy of the entire colon is incomplete and/or contraindicated due to colon obstruction or coagulopathy.
Wisconsin Physician Service (WPS)	IL, IN, MI, WI	Final	Indicated when a fiberoptic colonoscopy of the entire colon is incomplete due to an inability to pass the colonoscope proximally. Also indicated for the evaluation of a submucosal abnormality detected on colonoscope or other imaging study.
CIGNA	ID	Final	Indicated when an instrument colonoscopy of entire colon is incomplete due to an obstructing lesion resulting in an inability to pass the colonoscope proximally. Intended for use in pre-operative situations when knowledge of the unvisualized colon proximal to the obstruction would be of use to the surgeon in planning the operative approach to the patient.
CIGNA	NC, TN	Final	Indicated when an instrument colonoscopy of entire colon is incomplete due to an obstructing neoplasm resulting in an inability to pass the colonoscope proximally. Intended for use in pre-operative situations when knowledge of the unvisualized colon proximal to the obstruction would be of use to the surgeon in planning the operative approach to the patient.
Empire Medicare Services	NY	Final	Indicated when a fiberoptic colonoscopy of entire colon is incomplete due to an inability to pass the colonoscope proximally.
Empire Medicare Services	NJ	Final	Indicated when a fiberoptic colonoscopy of entire colon is incomplete due to an inability to pass the colonoscope proximally.
HealthNow-UMD	NY	Final	Indicated when a fiberoptic colonoscopy of entire colon is incomplete due to an inability to pass the colonoscope proximally.
HGSA	PA	Final	Indicated when a fiberoptic colonoscopy of entire colon is incomplete due to an inability to pass the colonoscope proximally. CT colonography may also be medically reasonable and necessary for those patients in whom a standard colonoscopy is contraindicated.
National Heritage Insurance Company (NHIC) -- The Medicare Part B contractor for CA, ME, MA, NH, and VT, serving 5.5 million beneficiaries and 178,000 healthcare providers.	CA	Final	Indicated when an instrument colonoscopy of entire colon is incomplete.
National Heritage Insurance Company (NHIC) New England	MA, ME, NH, VT	Final	Indicated when an instrument colonoscopy of entire colon is incomplete.