Adding coverage for CPT code 81528, Cologuard (Multi-target stool DNA-based colorectal screening)

Effective July 1, 2018, Cologuard (CPT code 81528) has been approved for colorectal cancer screening (CRC). Developed by Exact Sciences, Cologuard is a non-invasive screening that is delivered to the home. The screening can detect colorectal neoplasms associated with DNA markers and the presence of occult blood. Cologuard for CRC is for males or females with average risk of CRC who are between the ages of 50 and 85. It is covered by Medicaid once every three years. Cologuard is not intended to replace diagnostic colonoscopy in high-risk beneficiaries.

1. Cologuard is not indicated for the following:
2. Beneficiary with a family or personal history of colorectal cancer
3. Previous positive test from another colorectal screening test within the last six months
   1. Conditions associated with high risk:
   2. Inflammatory Bowel Disease
   3. Crohn’s disease
   4. Chronic Ulcerative Colitis
   5. History of Polyps
   6. Neurofibromatosis
   7. Relevant familiar (heredity) cancer syndrome such as Lynch syndrome