G0464, Colorectal cancer screening; stool-based dna and fecal occult hemoglobin (e.g.,
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- When colonoscopy is performed after a positive non-invasive test: documentation of colonoscopy findings, polypectomy/pathology results, and follow-up plan is required (implied throughout text).
- For CF-specific recommendations: documentation of CF diagnosis and use of CF-specific intensive bowel preparation is expected when following CF Foundation recommendations (text).
- Screening is considered medically necessary when tests are 'recommended by their physician' (physician recommendation documented in the medical record).
- Coverage is conditional on 'selection criteria are met' for listed CPT/HCPCS codes — the policy requires that applicable clinical selection criteria/indications be documented in the record.
Key Coverage Criteria
- Colonoscopy (considered medically necessary every 10 years for persons at average risk);
- Specific biopsy procedural/collection requirements (covered when medically necessary):
- Inflammatory bowel disease, diagnosis - 2 or more biopsies from 5 different locations, including the ileum and rectum;
- The USPSTF recommended screening for CRC in all adults aged 50 to 75 years (A recommendation).
- Constipation (K59.00 - K59.09)
- Noninfective enteritis and colitis (K51.00 - K55.9)
1 Active Policy
AETNA-CPB-0516, Colonoscopy, Colorectal Cancer Screening, and Related Procedures
Related Codes
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