Coverage Mandate: Colorectal Cancer Screening

The Texas Insurance Code now mandates coverage for colorectal cancer screening services by health plans. This policy applies to most health plans issued or renewed on or after Jan. 1, 2002. The health plans also must give written notice regarding coverage to each person enrolled in the plan.

The minimum benefits must include, for enrollees who are 50 or older and at normal risk for developing colon cancer:

  • A fecal-occult blood test performed annually and a flexible sigmoidoscopy performed every five years, or
  • A colonoscopy performed every 10 years.

Although Medicare also allows coverage for colorectal cancer screening, benefit guidelines are somewhat different. Medicare benefits include:

 

  • A fecal-occult blood test performed once every 12 months for beneficiaries who are 50 or older,
  • A flexible sigmoidoscopy performed once every 48 months for beneficiaries who are 50 or older,
  • A colonoscopy performed once every 24 months for beneficiaries at high risk for colorectal cancer or once every 10 years (but not within 48 months of a screening sigmoidoscopy if the patient is not at high risk for colon cancer, and
  • Screening barium enema examinations performed as an alternative to either a screening sigmoidoscopy or screening colonoscopy in some situations.

Patients at high risk for colorectal cancer are those who, because of family history, prior experience of cancer or precursor neoplastic polyps, history of chronic digestive conditions (including inflammatory bowl diseases, Crohn's disease, or ulcerative colitis), the presence of any appropriate gene markers for colorectal cancer, or other predisposing factors, are susceptible to the disease.

For additional information about Medicare coverage, see the Centers for Medicare and Medicaid Services' Web page on colorectal cancer screening .

Applicable HCPCS codes

 

G0107

Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations

G0104

Colorectal cancer screening; flexible sigmoidoscopy

G0105

Colorectal cancer screening; colonoscopy on individual at high risk

G0121 Colorectal screening; colonoscopy on individual not meeting criteria for high risk

Applicable ICD-9 codes

 

V16.0

Family history of malignant gastrointestinal tract neoplasm

V76.41

Special screening for malignant neoplasm, rectum

V76.51

Special screening for malignant neoplasm, colon

The new coverage mandate is in Texas Insurance Code Chapter 21, Article 21.53S, and 28 TAC §§ 21.2101-21.2106.

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