We’re making some coding and benefit changes related to colonoscopies, effective for dates of service beginning Oct. 1, 2026 for our Harvard Pilgrim Health Care Commercial and Tufts Health Direct products.

As a result, we’ll be updating the Patient Protection and Affordable Care Act (Federal Health Care Reform) policies in our Harvard Pilgrim Commercial and Tufts Health Public Plans Provider Manuals as of Oct. 1, and have also developed Colonoscopy Medical Necessity Guidelines (MNG). 

The new MNG and updated PPACA policies will reflect a change to our preventive colonoscopy benefit: a large number of medical conditions which were previously considered preventive will be more appropriately categorized as diagnostic or therapeutic in alignment with industry standard guidance. (As a reminder, while members are exempt from cost-sharing responsibilities for preventive services rendered by an in-network provider in accordance with PPACA, cost-sharing is applied to services classified as diagnostic or therapeutic.)

CPT codes 45385, 45380, and 45378 are considered medically necessary when submitted with an appropriate ICD-10 code, and the MNG indicates which covered medical conditions are categorized as diagnostic, therapeutic, or preventive. 

Additionally, when a preventive screening colonoscopy turns diagnostic/therapeutic in nature (e.g. biopsy, polypectomy) providers will be required to include a preventive diagnosis on the claim and include modifier 33 in the first modifier field.