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									                                                             Summary of Draft and Final CT Colonography LCDs


CONTRACTOR NAME                  CARRIER/M STATE          LCD      LCD ID   LCD Title                 INDICATIONS OF COVERAGE                   LIMITATIONS OF COVERAGE
                                 AC                       STATUS
Noridian Administrative Services MAC       Arizona        Final    L24293   CT Colonography           Computed tomographic (CT)                 CT colonography is not a covered
                                                                                                      colonography, also known as virtual       service when utilized in preoperative
                                                                                                      colonoscopy, utilizes helical computed    cancer staging, and in this clinical
                                                                                                      tomography of the abdomen and pelvis      situation NAS believes that standard CT
Noridian Administrative Services MAC       Montana        Final    L24293   CT Colonography           Computed tomographic (CT)                 CT colonography is not a covered
                                                                                                      colonography, also known as virtual       service when utilized in preoperative
                                                                                                      colonoscopy, utilizes helical computed    cancer staging, and in this clinical
                                                                                                      tomography of the abdomen and pelvis      situation NAS believes that standard CT
Noridian Administrative Services MAC       North Dakota   Final    L24293   CT Colonography           Computed tomographic (CT)                 CT colonography is not a covered
(NAS)                                                                                                 colonography, also known as virtual       service when utilized in preoperative
                                                                                                      colonoscopy, utilizes helical computed    cancer staging, and in this clinical
                                                                                                      tomography of the abdomen and pelvis      situation NAS believes that standard CT
Noridian Administrative Services MAC       South Dakota   Final    L24293   CT Colonography           Computed tomographic (CT)                 CT colonography is not a covered
(NAS)                                                                                                 colonography, also known as virtual       service when utilized in preoperative
                                                                                                      colonoscopy, utilizes helical computed    cancer staging, and in this clinical
                                                                                                      tomography of the abdomen and pelvis      situation NAS believes that standard CT
Noridian Administrative Services MAC       Utah           Final    L24293   CT Colonography           Computed tomographic (CT)                 CT colonography is not a covered
(NAS)                                                                                                 colonography, also known as virtual       service when utilized in preoperative
                                                                                                      colonoscopy, utilizes helical computed    cancer staging, and in this clinical
                                                                                                      tomography of the abdomen and pelvis      situation NAS believes that standard CT
Noridian Administrative Services MAC       Wyoming        Final    L24293   CT Colonography           Computed tomographic (CT)                 CT colonography is not a covered
(NAS)                                                                                                 colonography, also known as virtual       service when utilized in preoperative
                                                                                                      colonoscopy, utilizes helical computed    cancer staging, and in this clinical
                                                                                                      tomography of the abdomen and pelvis      situation NAS believes that standard CT
Noridian Administrative Services Carrier   Alaska         Final    L23717   CT Colonography           Computed tomographic (CT)                 CT colonography is not a covered
(NAS)                                                                                                 colonography, also known as virtual       service when utilized in preoperative
                                                                                                      colonoscopy, utilizes helical computed    cancer staging, and in this clinical
                                                                                                      tomography of the abdomen and pelvis      situation NAS believes that standard CT
Noridian Administrative Services Carrier   Oregon         Final    L23717   CT Colonography           Computed tomographic (CT)                 CT colonography is not a covered
(NAS)                                                                                                 colonography, also known as virtual       service when utilized in preoperative
                                                                                                      colonoscopy, utilizes helical computed    cancer staging, and in this clinical
                                                                                                      tomography of the abdomen and pelvis      situation NAS believes that standard CT
Noridian Administrative Services Carrier   Washington     Final    L23717   CT Colonography           Computed tomographic (CT)                 CT colonography is not a covered
(NAS)                                                                                                 colonography, also known as virtual       service when utilized in preoperative
                                                                                                      colonoscopy, utilizes helical computed    cancer staging, and in this clinical
                                                                                                      tomography of the abdomen and pelvis      situation NAS believes that standard CT
Cahaba Government Benefit        Carrier   Alabama
Administrators (Cahaba GBA)

Cahaba Government Benefit        Carrier   Georgia
Administrators (Cahaba GBA)

Cahaba Government Benefit        Carrier   Mississippi
Administrators (Cahaba GBA)

Pinnacle Business Solutions,     Carrier   Arkansas       Final    L22039   CT Colonography (Virtual Virtual colonoscopy is only indicated in   1. Virtual colonography is not
Inc. (PBSI)                                                                 Colonoscopy)             those patients in whom an                  reimbursable when used for screening,
                                                                                                     instrument/fiberoptic colonoscopy of the   or in the absence of signs of symptoms
                                                                                                     entire colon is incomplete due to an       of disease, regardless of family history,
Pinnacle Business Solutions,     Carrier   Louisiana      Final    L22039   CT Colonography (Virtual Virtual colonoscopy is only indicated in   1. Virtual colonography is not
Inc. (PBSI)                                                                 Colonoscopy)             those patients in whom an                  reimbursable when used for screening,
                                                                                                     instrument/fiberoptic colonoscopy of the   or in the absence of signs of symptoms
                                                                                                     entire colon is incomplete due to an       of disease, regardless of family history,



                                                                                Page 1 of 4
                                                                Summary of Draft and Final CT Colonography LCDs


CONTRACTOR NAME                  CARRIER/M STATE             LCD      LCD ID   LCD Title                 INDICATIONS OF COVERAGE                   LIMITATIONS OF COVERAGE
                                 AC                          STATUS
National Heritage Insurance      Carrier   Rhode Island      Final    L17259   Virtual Colonoscopy (CT   *Virtual colonoscopy also known as CT *Virtual colonoscopy is not reimbursable
Corporation (NHIC)                                                             Colonography)             colonography utilizes helical computed      when used for screening, or in the
                                                                                                         tomography of the abdomen and pelvis absence of signs or symptoms of
                                                                                                         to visualize the colon lumen, along with 3- disease, regardless of family history or
National Heritage Insurance      Carrier    Massachussets    Final    L17259   Virtual Colonoscopy (CT   *Virtual colonoscopy also known as CT *Virtual colonoscopy is not reimbursable
Corporation (NHIC)                                                             Colonography)             colonography utilizes helical computed      when used for screening, or in the
                                                                                                         tomography of the abdomen and pelvis absence of signs or symptoms of
                                                                                                         to visualize the colon lumen, along with 3- disease, regardless of family history or
National Heritage Insurance      Carrier    Maine            Final    L17259   Virtual Colonoscopy (CT   *Virtual colonoscopy also known as CT *Virtual colonoscopy is not reimbursable
Corporation (NHIC)                                                             Colonography)             colonography utilizes helical computed      when used for screening, or in the
                                                                                                         tomography of the abdomen and pelvis absence of signs or symptoms of
                                                                                                         to visualize the colon lumen, along with 3- disease, regardless of family history or
National Heritage Insurance      Carrier    New Hampshire    Final    L17259   Virtual Colonoscopy (CT   *Virtual colonoscopy also known as CT *Virtual colonoscopy is not reimbursable
Corporation (NHIC)                                                             Colonography)             colonography utilizes helical computed      when used for screening, or in the
                                                                                                         tomography of the abdomen and pelvis absence of signs or symptoms of
                                                                                                         to visualize the colon lumen, along with 3- disease, regardless of family history or
National Heritage Insurance      Carrier    Vermont          Final    L17259   Virtual Colonoscopy (CT   *Virtual colonoscopy also known as CT *Virtual colonoscopy is not reimbursable
Corporation (NHIC)                                                             Colonography)             colonography utilizes helical computed      when used for screening, or in the
                                                                                                         tomography of the abdomen and pelvis absence of signs or symptoms of
                                                                                                         to visualize the colon lumen, along with 3- disease, regardless of family history or
Trailblazer Health Enterprises   MAC        Colorado         Final    L26745   Computed Tomography       Those patients in whom a standard           CT colonography is not reimbursable
                                                                               (CT) Colonography         (fiberoptic, video) colonoscopy of the      when used for screening (Category III
                                                                                                         entire colon is incomplete due to an        Code 0066T) or in the absence of signs
                                                                                                         inability to pass the colonoscope           or symptoms of disease, regardless of
Trailblazer Health Enterprises   MAC        New Mexico       Final    L26745   Computed Tomography       Those patients in whom a standard           CT colonography is not reimbursable
                                                                               (CT) Colonography         (fiberoptic, video) colonoscopy of the      when used for screening (Category III
                                                                                                         entire colon is incomplete due to an        Code 0066T) or in the absence of signs
                                                                                                         inability to pass the colonoscope           or symptoms of disease, regardless of
Trailblazer Health Enterprises   MAC        Oklahoma         Final    L26745   Computed Tomography       Those patients in whom a standard           CT colonography is not reimbursable
                                                                               (CT) Colonography         (fiberoptic, video) colonoscopy of the      when used for screening (Category III
                                                                                                         entire colon is incomplete due to an        Code 0066T) or in the absence of signs
                                                                                                         inability to pass the colonoscope           or symptoms of disease, regardless of
Trailblazer Health Enterprises   MAC        Texas            Final    L26745   Computed Tomography       Those patients in whom a standard           CT colonography is not reimbursable
                                                                               (CT) Colonography         (fiberoptic, video) colonoscopy of the      when used for screening (Category III
                                                                                                         entire colon is incomplete due to an        Code 0066T) or in the absence of signs
                                                                                                         inability to pass the colonoscope           or symptoms of disease, regardless of
Trailblazer Health Enterprises   Carrier    Virginia         Final    L22991   Gastrointestinal Tract    CT colonography is indicated for:           CT colonography is not reimbursable
                                                                               Diagnostic Evaluation                                                 when used for screening (Category III
                                                                                                         Those patients in whom a standard           Code 0066T) or in the absence of signs
                                                                                                         (fiberoptic, video) colonoscopy of the      or symptoms of disease, regardless of
Cigna Government Services        Carrier    Idaho            Final    L18717   Virtual Colonoscopy (CT   CT colonography also known as virtual       CT colonography is not reimbursable
                                                                               Colonography)             colonoscopy utilizes helical computed       when used for screening, or in the
                                                                                                         tomography of the abdomen and pelvis absence of signs or symptoms of
                                                                                                         to visualize the colon lumen, along with disease, regardless of family history or
Cigna Government Services        Carrier    North Carolina   Final    L18987   Virtual Colonoscopy (CT   CT colonography also known as virtual       CT colonography is not reimbursable
                                                                               Colonography)             colonoscopy utilizes helical computed       when used for screening, or in the
                                                                                                         tomography of the abdomen and pelvis absence of signs or symptoms of
                                                                                                         to visualize the colon lumen, along with disease, regardless of family history or
Cigna Government Services        Carrier    Tennessee        Final    L18631   Virtual Colonoscopy (CT   CT colonography also known as virtual       CT colonography is not reimbursable
                                                                               Colonography)             colonoscopy utilizes helical computed       when used for screening, or in the
                                                                                                         tomography of the abdomen and pelvis absence of signs or symptoms of
                                                                                                         to visualize the colon lumen, along with disease, regardless of family history or
Wisconsin Physians Service       Carrier    Illinois         Final    L19902   CT Colonography           CT colonography also known as Virtual The screening colonoscopy benefit being
Insurance Corporation (WPS)                                                    (VIRTUAL                  Colonoscopy (VC) utilizes helical           under national (CMS) authority and,
                                                                               COLONOSCOPY [VC])         computed tomography of the abdomen          therefore, not under Carrier discretion,
                                                                                                         and pelvis to visualize the colon lumen, VC is never covered, under the auspices



                                                                                   Page 2 of 4
                                                               Summary of Draft and Final CT Colonography LCDs


CONTRACTOR NAME                 CARRIER/M STATE             LCD      LCD ID   LCD Title                  INDICATIONS OF COVERAGE                     LIMITATIONS OF COVERAGE
                                AC                          STATUS
Wisconsin Physians Service      Carrier   Michigan          Final    L19904   CT Colonography            CT colonography also known as Virtual       The screening colonoscopy benefit being
Insurance Corporation (WPS)                                                   (VIRTUAL                   Colonoscopy (VC) utilizes helical           under national (CMS) authority and,
                                                                              COLONOSCOPY [VC])          computed tomography of the abdomen          therefore, not under Carrier discretion,
                                                                                                         and pelvis to visualize the colon lumen,    VC is never covered, under the auspices
Wisconsin Physians Service      Carrier    Minnesota        Final    L19906   CT Colonography            CT colonography also known as Virtual       The screening colonoscopy benefit being
Insurance Corporation (WPS)                                                   (VIRTUAL                   Colonoscopy (VC) utilizes helical           under national (CMS) authority and,
                                                                              COLONOSCOPY [VC])          computed tomography of the abdomen          therefore, not under Carrier discretion,
                                                                                                         and pelvis to visualize the colon lumen,    VC is never covered, under the auspices
Wisconsin Physians Service      Carrier    Wisconsin        Final    L19899   CT Colonography            CT colonography also known as Virtual       The screening colonoscopy benefit being
Insurance Corporation (WPS)                                                   (VIRTUAL                   Colonoscopy (VC) utilizes helical           under national (CMS) authority and,
                                                                              COLONOSCOPY [VC])          computed tomography of the abdomen          therefore, not under Carrier discretion,
                                                                                                         and pelvis to visualize the colon lumen,    VC is never covered, under the auspices
Wisconsin Physians Service      MAC        Iowa             Final    L26704   CT Colonography            The incidence, cases diagnosed per          CT COLONOGRAPHY will NOT be
Insurance Corporation (WPS)                                                   (VIRTUAL                   year, of coloreCTal cancer in Western       covered for the following:
                                                                              COLONOSCOPY [VC])          countries, is 31-47 per 100,000 for men     1. When CT COLONOGRAPHY is
                                                                                                         and 22-33 per 100,000 for women. A little   performed without a prior incomplete
Wisconsin Physians Service      MAC        Kansas           Final    L26704   CT Colonography            The incidence, cases diagnosed per          CT colonography will NOT be covered for
Insurance Corporation (WPS)                                                   (VIRTUAL                   year, of colorectal cancer in Western       the following:
                                                                              COLONOSCOPY [VC])          countries, is 31-47 per 100,000 for men     1. When CT colonography is performed
                                                                                                         and 22-33 per 100,000 for women. A little   without a prior incomplete
Wisconsin Physians Service      MAC        Missouri -       Final    L26704   CT Colonography            The incidence, cases diagnosed per          CT colonography will NOT be covered for
Insurance Corporation (WPS)                Northwestern                       (VIRTUAL                   year, of colorectal cancer in Western       the following:
                                                                              COLONOSCOPY [VC])          countries, is 31-47 per 100,000 for men     1. When CT colonography is performed
                                                                                                         and 22-33 per 100,000 for women. A little   without a prior incomplete
Wisconsin Physians Service      MAC        Nebraska         Final    L26704   CT Colonography            The incidence, cases diagnosed per          CT colonography will NOT be covered for
Insurance Corporation (WPS)                                                   (VIRTUAL                   year, of colorectal cancer in Western       the following:
                                                                              COLONOSCOPY [VC])          countries, is 31-47 per 100,000 for men     1. When CT colonography is performed
                                                                                                         and 22-33 per 100,000 for women. A little   without a prior incomplete colonoscopy;
Palmetto Government Benefits    Carrier    Ohio             Final    L22626   Virtual Colonoscopy (CT    CT colonography, also known as virtual      CPT Category III code 0066T. Computed
Administrators (Palmetto GBA)                                                 Colonography)              colonoscopy utilizes helical computed       tomographic (CT) colonography (ie,
                                                                                                         tomography of the abdomen and pelvis        virtual colonoscopy) screening is never
                                                                                                         along with 2D or 3D reconstruction to       covered.
Palmetto Government Benefits    Carrier    South Carolina   Final    L22669   Virtual Colonoscopy (CT    CT colonography, also known as virtual      CPT Category III code 0066T. Computed
Administrators (Palmetto GBA)                                                 Colonography)              colonoscopy utilizes helical computed       tomographic (CT) colonography (ie,
                                                                                                         tomography of the abdomen and pelvis        virtual colonoscopy) screening is never
                                                                                                         along with 2D or 3D reconstruction to       covered.
Palmetto Government Benefits    Carrier    West Virginia    Final    L22631   Virtual Colonoscopy (CT    CT colonography, also known as virtual      CPT Category III code 0066T. Computed
Administrators (Palmetto GBA)                                                 Colonography)              colonoscopy utilizes helical computed       tomographic (CT) colonography (ie,
                                                                                                         tomography of the abdomen and pelvis        virtual colonoscopy) screening is never
                                                                                                         along with 2D or 3D reconstruction to       covered.
Palmetto Government Benefits    MAC        California -     Final    L28250   CT Colonography (Virtual   CT colonography, also known as CT           CT colonography is not reimbursable
Administrators (Palmetto GBA)              Northern                           Colonoscopy)               virtual colonoscopy, utilizes helical       when used for screening, or in the
                                                                                                         computed tomography of the abdomen          absence of signs or symptoms of
                                                                                                         and pelvis to visualize the colon lumen,    disease, regardless of family history or
Palmetto Government Benefits    MAC        California -     Final    L28250   CT Colonography (Virtual   CT colonography, also known as CT           CT colonography is not reimbursable
Administrators (Palmetto GBA)              Southern                           Colonoscopy)               virtual colonoscopy, utilizes helical       when used for screening, or in the
                                                                                                         computed tomography of the abdomen          absence of signs or symptoms of
                                                                                                         and pelvis to visualize the colon lumen,    disease, regardless of family history or
Palmetto Government Benefits    MAC        Hawaii           Final    L28250   CT Colonography (Virtual   CT colonography, also known as CT           CT colonography is not reimbursable
Administrators (Palmetto GBA)                                                 Colonoscopy)               virtual colonoscopy, utilizes helical       when used for screening, or in the
                                                                                                         computed tomography of the abdomen          absence of signs or symptoms of
                                                                                                         and pelvis to visualize the colon lumen,    disease, regardless of family history or
Palmetto Government Benefits    MAC        Nevada           Final    L28250   CT Colonography (Virtual   CT colonography, also known as CT           CT colonography is not reimbursable
Administrators (Palmetto GBA)                                                 Colonoscopy)               virtual colonoscopy, utilizes helical       when used for screening, or in the
                                                                                                         computed tomography of the abdomen          absence of signs or symptoms of
                                                                                                         and pelvis to visualize the colon lumen,    disease, regardless of family history or



                                                                                  Page 3 of 4
                                                            Summary of Draft and Final CT Colonography LCDs


CONTRACTOR NAME                 CARRIER/M STATE          LCD      LCD ID   LCD Title              INDICATIONS OF COVERAGE                     LIMITATIONS OF COVERAGE
                                AC                       STATUS
Highmark Medicare Services      MAC       Delaware
(HMS)

Highmark Medicare Services      MAC       District of
(HMS)                                     Columbia

Highmark Medicare Services      MAC       Maryland
(HMS)

Highmark Medicare Services      MAC       New Jersey
(HMS)

Highmark Medicare Services      MAC       Pennsylvania
(HMS)

First Coast Service Options, Inc. MAC     Florida        Final    L29118   Computed Tomographic   Computed tomographic colonography           CT colonography will not be covered for
(FCSO)                                                                     Colonography           (CT colonography) also known as virtual     the following:
                                                                                                  colonoscopy is a technique used for the
                                                                                                  detection of colorectal polyps. There are   · When CT colonography is performed
First Coast Service Options, Inc. MAC     Puerto Rico    Final    L29136   Computed Tomographic   Computed tomographic colonography           CT colonography will not be covered for
(FCSO)                                                                     Colonography           (CT colonography) also known as virtual     the following:
                                                                                                  colonoscopy is a technique used for the
                                                                                                  detection of colorectal polyps. There are   · When CT colonography is performed
National Government Services    MAC       Connecticut    Final    L25233   Computed Tomographic   CT colonography is indicated in those       CT colonography is not reimbursable
(NGS)                                                                      (CT) Colonography      patients in whom a diagnostic (performed    when used in the absence of signs or
                                                                                                  for signs/symptoms of disease) optical      symptoms of disease, regardless of
                                                                                                  colonoscopy of the entire colon is          family history or other risk factors for the
National Government Services    Carrier   Indiana        Final    L25233   Computed Tomographic   CT colonography is indicated in those       CT colonography is not reimbursable
(NGS)                                                                      (CT) Colonography      patients in whom a diagnostic (performed    when used in the absence of signs or
                                                                                                  for signs/symptoms of disease) optical      symptoms of disease, regardless of
                                                                                                  colonoscopy of the entire colon is          family history or other risk factors for the
National Government Services    Carrier   Kentucky       Final    L25233   Computed Tomographic   CT colonography is indicated in those       CT colonography is not reimbursable
(NGS)                                                                      (CT) Colonography      patients in whom a diagnostic (performed    when used in the absence of signs or
                                                                                                  for signs/symptoms of disease) optical      symptoms of disease, regardless of
                                                                                                  colonoscopy of the entire colon is          family history or other risk factors for the
National Government Services    MAC       New York       Final    L25233   Computed Tomographic   CT colonography is indicated in those       CT colonography is not reimbursable
(NGS)                                                                      (CT) Colonography      patients in whom a diagnostic (performed    when used in the absence of signs or
                                                                                                  for signs/symptoms of disease) optical      symptoms of disease, regardless of
                                                                                                  colonoscopy of the entire colon is          family history or other risk factors for the




                                                                               Page 4 of 4

								
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