A Virtual Colonoscopy (VC), also known as Computed Tomography Colonography (CTC), is a non-invasive colorectal cancer screening tool that uses a CT scanner to create detailed, three-dimensional images of the colon. This allows physicians to examine the large intestine for polyps or tumors without inserting a flexible scope. Medicare covers the VC procedure, defined by a recent policy expansion and provided under strict criteria that determine when the service is considered a covered preventive benefit.
Current Coverage Status Under Medicare Part B
The Centers for Medicare & Medicaid Services (CMS) significantly expanded coverage for colorectal cancer screening by adding the Virtual Colonoscopy as a covered preventive service under Medicare Part B, effective January 1, 2025. This addition was formalized within the 2025 Medicare Physician Fee Schedule (MPFS) final rule, recognizing CTC as an appropriate screening method for early cancer detection.
Prior to this ruling, the procedure was generally not covered for routine screening purposes. The new policy ensures the service is covered when ordered by a treating physician for specific populations, primarily to detect pre-cancerous polyps. Coverage is provided through specific Healthcare Common Procedure Coding System (HCPCS) codes, such as 74263, when the procedure is used for screening.
For the procedure to be covered, the Virtual Colonoscopy must be performed in a facility that meets strict quality standards, ensuring accurate image acquisition and interpretation. Interpretation must be conducted by qualified medical personnel, typically a radiologist. This administrative oversight ensures the high-quality performance necessary for an effective screening tool. The federal policy change reflects an ongoing effort to align Medicare coverage with current medical evidence and the recommendations of major medical organizations.
Determining Eligibility and Screening Intervals
Medicare covers the screening Virtual Colonoscopy for beneficiaries aged 45 or older, aligning with updated screening recommendations. The patient must be asymptomatic, showing no signs or symptoms of colorectal disease, such as unexplained gastrointestinal pain or blood in the stool. Coverage is strictly for screening purposes and not for initial diagnostic evaluation.
For individuals considered at average risk, Medicare covers the Virtual Colonoscopy once in a five-year period. This requires at least 59 months to have passed since the last covered screening CTC. This five-year interval contrasts with the ten-year interval generally covered for a traditional screening colonoscopy in average-risk individuals.
High-risk patients are eligible for the procedure more frequently. Medicare covers the screening Virtual Colonoscopy once in a two-year period, requiring at least 23 months since the last covered screening. High-risk status is typically determined by a personal or family history of specific conditions, such as adenomatous polyps, inflammatory bowel disease, or prior colorectal cancer. The physician must document the appropriate high-risk criteria using specific ICD-10 diagnostic codes for the shorter interval to be covered.
Patient Costs and Medicare Advantage Policies
Medicare waives patient financial responsibility for the screening Virtual Colonoscopy. For this preventive service, Medicare waives both the Part B deductible and the standard 20% coinsurance. Beneficiaries who receive the screening CTC are responsible for paying nothing out-of-pocket, provided the healthcare provider accepts Medicare assignment. This elimination of cost-sharing is a deliberate measure by CMS to remove financial barriers.
If a separate, non-screening service is performed during the same encounter, the patient may incur cost-sharing for that additional service. For beneficiaries enrolled in a Medicare Advantage Plan (Part C), coverage for preventive services must be at least equivalent to Original Medicare. This means the screening Virtual Colonoscopy must be covered, and the zero-cost-sharing rule generally applies.
Out-of-pocket costs for other services, such as copayments or deductibles, vary under Medicare Advantage plans. While the screening CTC has no cost-sharing, a Part C plan may have different cost structures for follow-up diagnostic procedures or physician fees. Beneficiaries should check their specific plan documents, such as the Summary of Benefits, to understand any potential variance in cost-sharing for non-preventive services.
Comparing Virtual and Traditional Colonoscopy
Virtual Colonoscopy and traditional colonoscopy differ in their procedural approach and patient experience. Traditional colonoscopy is an invasive procedure involving a flexible scope inserted into the colon, typically requiring sedation. The CTC is minimally invasive, using a CT scan after the colon is inflated with air or carbon dioxide, and it does not require sedation. Both procedures require the same comprehensive bowel preparation beforehand.
A traditional colonoscopy allows the physician to immediately remove any polyps found during the examination. The Virtual Colonoscopy is an imaging study that can only detect polyps; it cannot remove them or take tissue samples for biopsy. If the VC is positive, identifying a polyp or suspicious lesion, the patient must undergo a follow-up traditional colonoscopy to complete the screening process.
Medicare policy now considers this necessary follow-up traditional colonoscopy as part of the complete colorectal cancer screening continuum. A follow-up colonoscopy performed after a positive Virtual Colonoscopy result is covered as a screening procedure, not a diagnostic one. As a result of this policy change, the patient incurs no cost-sharing for the follow-up traditional colonoscopy.