Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old male who has requested authorization for a virtual colonoscopy for colon cancer screening. The patient has been on Coumadin for recurrent atrial fibrillation and he is concerned that discontinuing his anticoagulation therapy prior to a standard colonoscopy will put him at risk. Therefore, he is seeking approval of a virtual colonoscopy. The Health Plan has denied his request on the basis that a virtual colonoscopy is not medically necessary.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. Virtual colonoscopy is a useful tool in patients who are at high risk to undergo sedation because of their cardiopulmonary status, patients with obstructive lesions of the distal colon who need preoperative evaluation of the rest of the colon, and patients in whom the colonoscopy is technically difficult because of adhesions secondary to previous surgery. This patient does not meet these criteria. He has underlying atrial fibrillation, which is well controlled. He can safely hold Coumadin for a few days after consulting with his cardiologist. A standard colonoscopy can be safely performed during regular working hours with full medical backup from cardiology if needed. Therefore, I have determined the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.