Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 55-year-old male who was referred by his provider for a screening colonoscopy in February 2005. The patient has no prior history of a screening colonoscopy and no prior history of a failed attempt or unsuccessful colonoscopy. The patient underwent a CT colonography (virtual colonoscopy) instead of a conventional optical colonoscopy, which revealed a normal appearing colon and two left renal calculi. At issue is whether the virtual colonoscopy was medically necessary for evaluation of the patients medical condition.Virtual colonoscopy represents a noninvasive test for the examination of the colonic lumen that involves the generation of both two-dimensional and three-dimensional views of the colon and rectum using data derived from computed tomography. This imaging modality has been explored as an alternative to conventional endoscopic colonoscopy, particularly as an alternative screening tool for colorectal cancer. Although virtual colonoscopy does not require sedation and requires less time for completion, the study requires the same bowel-cleansing preparation as conventional colonoscopy as well as gas insufflation of the intestine, which may be associated with patient discomfort. The Food and Drug Administration approved virtual colonoscopy technology in 1995. Virtual colonoscopy is being proposed as a method for non-invasive evaluation of the colon for colon cancer screening. However, several recently published studies that tested the efficacy of virtual colonoscopy to detect polyps have shown different results. In the multicenter U.S. study (Pickhardt, et. al.), 1233 asymptomatic average-risk adults (mean age, 58) underwent virtual colonoscopy followed immediately by conventional fiberoptic colonoscopy. Of 59 advanced lesions, virtual colonoscopy identified 54 and blinded conventional colonoscopy identified 52. However, another recently published study (Cotton, et. al.) showed virtual colonoscopy to have poor sensitivity in the detection of colon polyps. In this study, the sensitivity of virtual colonoscopy in detecting a polyp of 1cm in size or greater was only 55%. The findings from a recently published meta-analysis of studies comparing colonoscopy to virtual colonoscopy were that inconsistencies in the performance of virtual colonoscopy preclude it from being considered an appropriate test for colon cancer screening.Although virtual colonoscopy appears to be a promising imaging technique a larger body of literature must be accumulated to warrant the development of rational, evidence-based algorithms in order to determine the precise operating characteristics of virtual colonoscopy in different settings. While the procedure may be necessary as an alternative to conventional colonoscopy in high-risk patients who are unable to undergo colonoscopy for technical reasons (colonic strictures, cancer and intra-abdominal adhesions), this patient had no contraindications to conventional colonoscopy. As such, a virtual colonoscopy was not medically warranted.For the reasons stated above, I have determined the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.