CPT 45378, in plain terms, covers Physician uses flexible colonoscope to visually examine the entire colon from cecum to rectum. CPT 45378 is referenced in 15 tracked payer policy changes from UnitedHealthcare, Medicare/CMS - Transmittals, and 6 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 45378 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 45378 on AAPC
UnitedHealthcare is removing a long list of CPT codes from the applicable-code list of its Outpatient Surgical Procedures site-of-service policy for Exchange plans, and it is also removing the link to the Manipulation Under Anesthesia policy. The change takes effect December 1, 2026. The source does not state a new billing requirement for the removed codes.
Effective December 1, 2026, UMR removes more than 500 CPT codes from its Outpatient Surgical Procedures - Site of Service medical policy for commercial plans, and it drops a reference link to the Manipulation Under Anesthesia policy. For those codes, UMR's site-of-service policy no longer applies, so the practice should update its internal UMR site-of-service and prior authorization lists before that date.
Effective December 1, 2026, UnitedHealthcare removes more than 500 CPT codes from its Outpatient Surgical Procedures - Site of Service medical policy for commercial plans, and it drops a reference link to the Manipulation Under Anesthesia policy. For those codes, the site-of-service policy no longer applies under this UnitedHealthcare commercial policy, so the practice should update its internal site-of-service and prior authorization lists before that date.
All HCPCS Level II codes remain effective until CMS announces otherwise, and they are not designated as temporary or permanent. The Medicare Physician Fee Schedule Database (MPFSDB) file layout is revised to accommodate two different conversion factors under the Quality Payment Program. The updates apply to Medicare Claims Processing Manual Chapter 23 sections 20.3, 20.4 and 20.8 and the MPFSDB addendum, with an effective date of November 16, 2026 and a date-of-service effective date unless otherwise specified.
Effective October 1, 2026, Harvard Pilgrim Health Care Commercial and Tufts Health Direct are reclassifying many colonoscopy-related medical conditions from preventive to diagnostic or therapeutic services. This means affected services will now require patient cost-sharing. When a preventive screening colonoscopy becomes diagnostic/therapeutic (e.g., biopsy, polypectomy), providers must bill with a preventive diagnosis code and modifier 33 in the first modifier field.
This policy, effective 09/01/26, requires site-of-service review and, when applicable, prior authorization for specified outpatient procedures performed in a hospital outpatient setting, and the lowest appropriate level of care capable of safely performing the procedure is preferred in the absence of a clinical contraindication. A hospital outpatient facility instead of an ambulatory surgery center for a planned outpatient procedure is medically necessary with documentation of ANY of 38 listed criteria, including age 18 years or younger, prolonged surgery (>3 hours), morbid obesity (BMI 40 or higher), pregnancy, ASA Physical Status classification III or higher, moderate to severe obstructive sleep apnea, or uncontrolled epilepsy. The policy covers specified musculoskeletal, digestive and urinary system CPT codes.
Aetna updated their National Precertification List with multiple new drug requirements and removed precertification for BRCA genetic testing. Several new specialty drugs now require precertification with staggered effective dates from March through April 2025, and new claim edits will be implemented starting July 1, 2025.
Premera's December 2024 medical policy and coding update adds medical necessity criteria for lymphedema and lipedema surgery, a new shoulder arthroplasty policy, and new or revised criteria for drugs including Ocrevus Zunovo, Dupixent, Ebglyss, Leqselvi and Wegovy. It also lists coding updates that require review for medical necessity and prior authorization, including cervical spine surgery codes 63001, 63015, 63040, 63050, 63051, 63075, 63081 and 63265, and it places infusion drugs such as Tyruko and Alyglo under site-of-service review.
Effective November 1, 2026, the Surgical Site of Care policy for colonoscopy and sigmoidoscopy codes applies site of care medical necessity review only when the procedure is performed in an outpatient hospital setting. Use of a hospital outpatient department instead of an ambulatory surgery center or physician office may be considered medically necessary when one or more listed criteria are met, such as no geographically accessible in-network ASC that has the necessary equipment, a procedure that requires discontinuing medications that necessitate inpatient monitoring, ASA Physical Status III or higher, or a BMI over 40. When none of the criteria are met, hospital outpatient use is considered not medically necessary.
Effective November 1, 2026, use of a hospital outpatient department instead of an ambulatory surgery center or physician office for surgical services may be considered medically necessary when one of the listed criteria is met, such as no geographically accessible in-network ASC within 25 miles of the individual's residence that has the necessary equipment, a procedure that requires discontinuing medications that necessitate inpatient monitoring, an American Society of Anesthesiologists Physical Status classification of III or higher, a body mass index over 40, or a prolonged surgery over 3 hours. Site of care medical necessity reviews apply to the listed colonoscopy, sigmoidoscopy and colorectal screening codes only when they are performed in an outpatient hospital setting, and use of a hospital outpatient department when the criteria are not met is considered not medically necessary.
Effective August 1, 2026, Blue Shield of California's Place of Service policy for outpatient procedures (BSC10.01) considers an outpatient hospital surgical facility (POS 19 or 22) medically necessary when a listed clinical risk applies or when an appropriate ambulatory surgery center is not reasonably accessible. An ambulatory surgery center (POS 24) is considered medically necessary when all listed criteria are met, and it is not medically necessary for patients requiring a complex surgical approach or situation, or for all other indications outside the medically necessary criteria. Use of an inpatient hospital facility (POS 21) solely for a procedure that could safely be performed in an outpatient setting is not medically necessary.
Aetna's Clinical Policy Bulletin 0783 (reviewed 2026-10-27) confirms that in vivo analysis technologies for gastrointestinal and urothelial lesions, including confocal laser endomicroscopy, narrow-band imaging, chromoendoscopy and optical biopsy systems, are considered experimental, investigational or unproven for the listed indications. Claims for these services with the listed CPT codes (such as 43206, 43252 and +0397T) and ICD-10 diagnoses will be denied under this policy, so billing staff should review how these services are coded and documented before submission.
Aetna Clinical Policy Bulletin 0783 addresses in vivo analysis of gastrointestinal and urothelial lesions. It considers confocal laser endomicroscopy, including Cellvizio probe-based confocal laser endomicroscopy, and in-vivo analysis of colorectal polyps experimental, investigational, or unproven for the indications listed, because the effectiveness of these approaches has not been established. The source lists CPT and ICD-10 codes as not covered for the indications in the policy and gives a last review date of 10/26/2026.
Aetna Clinical Policy Bulletin 0783 considers confocal laser endomicroscopy (including Cellvizio probe-based confocal laser endomicroscopy) experimental, investigational, or unproven for the indications it lists, because the effectiveness of these approaches has not been established. The listed indications include assessment of safe surgical margins during laryngectomy, confirmation of low-grade dysplasia and surveillance of Barrett's esophagus, diagnosis and histologic grading of bladder cancer, diagnosis and staging of lung cancer, diagnosis of prostate cancer, diagnosis of head and neck squamous cell carcinoma, differentiation of colorectal polyps during routine colonoscopy, and diagnosis of indeterminate biliary strictures and pancreatic lesions. The policy also lists elastic-scattering spectroscopy for colonic polyps, ERCP with optical endomicroscopy for biliary lesions, and in vivo analysis of colorectal polyps (including chromoendoscopy, endocytoscopy, narrow-band imaging, multi-band imaging and the Optical Biopsy System) as experimental, investigational, or unproven.
Already effective between September 2, 2024 and January 1, 2025: precertification is required for Winrevair, Hercessi, Imdelltra, Rytelo, Yesafili, Opuviz, Ahzantive, Piasky, Kisunla, Yimmugo, Nypozi, Bkemv and Epysqli, and precertification is no longer required for Medicare members for Durolane, Euflexxa, Synvisc, Synvisc-One, Firmagon, Eligard and Zarxio effective October 1, 2024. Effective January 1, 2025, pathology codes 88300-88309 and 88331-88334 deny when billed on the same date of service as Mohs micrographic surgery codes 17311-17315, professional claims with a PC/TC indicator of '= 5' are not payable for hospital inpatients or patients in a hospital outpatient department, and Cologuard performed within one year after a completed colonoscopy will be denied. Also effective January 1, 2025, pharmacogenomic panel claims for Medicare members must be billed with CPT 81418, and Aetna International stateside members with a United States service address join the Enhanced Clinical Review Program for commercial members.
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