When a patient receives a positive result from a stool-based colorectal cancer screening test, a follow-up colonoscopy must be performed1-3. Stool-based tests (SBT) can only project the chances of a colorectal cancer or precancer, colonoscopy can conclusively tell if a patient has one of these. Follow-up colonoscopy also facilitates polyp removal and characterization, providing a patient with the full preventive benefit of their chosen screening modality. Recent changes in federal guidance recommends that commercial, employer, Medicare, and expanded Medicaid plans cover a follow-up colonoscopy after a positive SBT result without patient cost share4-6,a.
Nearly twice as many patients died of CRC who did not complete a follow-up colonoscopy after a positive FIT result7
Jan. 1, 2023
New policy changes took effect 1/1/23 recommending removal of patient cost share for a follow-up colonoscopy after a positive SBT result for many insurance plans4-6,a
GUIDELINE RECOMMENDATIONS: COLONOSCOPY AFTER POSITIVE STOOL-BASED TEST
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Timely Follow-up of positive stool tests with colonoscopy is recommended by all major screening guidelines1-3 |
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US Preventive Services Task Force (USPSTF) 20211 |
“When stool-based tests reveal abnormal results, follow-up with colonoscopy is needed for further evaluation.” |
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| American Cancer Society (ACS) 20182 |
“[For non-colonoscopy CRC screening stool tests] positive results require colonoscopy.” |
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| American College of Gastroenterology (ACG) 20213 |
"For non-colonoscopy CRC screening tests, “positive results require colonoscopy.” |
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Follow-up Colonoscopy Cost
- Cost is often listed as a primary barrier for a patient to complete a follow-up colonoscopy8,9
- Greater than 94% of patients Nationwide who use mt-sDNA have no out-of-pocket costs for screening10,b
- Greater than 93% of mt-sDNA patients aged 45-49 have had no out-of-pocket costs10,b
- However, recent updates to federal guidance recommend removal of cost sharing on many insurance plans (see below)
COVERAGE REQUIREMENTS FOR COLONOSCOPIES AFTER POSITIVE STOOL-BASED TESTS4-6,a
There is new federal guidance that incorporates updated United States Preventive Services Task Force recommendations for health insurance plans beginning on or after May 31, 2022
- A follow-up colonoscopy after a positive, noninvasive CRC screening test is a covered preventive service without patient cost share
- Applies to most commercial group and individual health insurance plans, including employer sponsored plans, expanded Medicaid plans, and Medicare plans
- Because all plan and benefit designs are different, and the rules differ if a provider is out-of-network, patients and providers are encouraged to ask their individual insurers about coverage
- This change is effective for most commercial plans upon the start of the January 1, 2023, plan year
References
1 Davidson KW, et al. Screening for colorectal cancer: US Preventative Task Force recommendation statement. JAMA. 2021;325(19):1965-1977.
2 Wolf AMD, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018;68(4):250-281.
3 Shaukat A, et al. ACG clinical guidelines: colorectal cancer screening 2021. Am J Gastroenterol. 2021;116(3):458-479.
4 US Department of Labor. FAQs about Affordable Care Act implementation part 51, Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act Implementation. Updated January 10, 2022. Accessed June 4, 2023. https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-51.pdf
5 CMS. HHS finalizes physician payment rule strengthening access to behavioral health service and whole-person care. Published November 1, 2022. Accessed June 4, 2023. https://www.cms.gov/newsroom/press-releases/hhs-finalizes-physician-payment-rule-strengthening-access-behavioral-health-services-and-whole
6 HealthCare.gov. Grandfathered health plan. Accessed June 4, 2023. https://www.healthcare.gov/glossary/grandfathered-health-plan/#:~:text=An%20individual%20health%20insurance%20policy,under%20the%20Affordable%20Care%20Act
7 Zorzi M, Battagello J, Selby K, et al. Non-compliance with colonoscopy after a positive faecal immunochemical test doubles the risk of dying from colorectal cancer. Gut. 2022 ;71(3):561-567.
8 Cooper GS, et al. Barriers to follow-up colonoscopy after positive FIT or multitarget stool DNA testing. J Am Board Fam Med. 2021;34(1):61-69.
9 Jetelina KK, et al. Patient-reported barriers to completing a diagnostic colonoscopy following abnormal fecal immunochemical test among uninsured patients. J Gen Intern Med. 2019;34(9):1730-1736.
10 Internal Data on File. Exact Sciences Corporation. Madison, WI.
Footnotes
a Because all plan and benefit designs are different, and the rules differ if a provider is out-of-network, patients and providers are encouraged to ask their individual insurers about coverage.
b Exact Sciences estimate based on historical patient billing as of April 30, 2022. Rate of coverage varies by state and region. Exceptions for coverage may apply; only your patients' insurers can confirm how Cologuard would be covered.
Last Updated:06/04/2023