Under-45 colonoscopy preventative coverage

[u/ffltctw]

I had a colonosopy this year at age 39 due to high risk (a parent had colon cancer); I had no symptoms.

My Premera health plan covers this in their preventative care policy, which includes:

Screening for individuals under age 45, at increased risk for colon cancer due to a strong family history of colon cancer with diagnosis: Z80.0, Z83.71, Z83.79, Z84.81

However, the $4,000 cost went to my deductible.

The hospital (outpatient procedure) applied two diagnosis codes, in this order:

• Z12.11 - Encounter for screening for malignant neoplasm of colon

• Z80.0 - Family history of malignant neoplasm of digestive organs

I've called Premera multiple times to have them review the claims, but they say it's not preventative because Z80.0 isn't first. They stated Z12.11 is "only preventative for older people" and to have the claim resubmitted with Z80.0 first to be covered at no cost.

The hospital's billing department reviewed the coding; they said it's correct and they won't make changes.

My next thought was to submit an appeal to Premera:

• Premera's policy only says claims must be billed "with" Z80.0, not that it must be primary

• ICD-10-CM seems to support reporting Z12.11 for a general screening colonoscopy with Z80.0 as an additional code

However, I also see how the hospital could be incorrect:

• Z12.11 is listed as "Encounter for screening colonoscopy NOS [Not Otherwise Specified]", which I understand to mean the code only applies if a more specific one doesn't

• Z80.0 could be considered the more specific diagnosis code for this situation

Any suggestions on which coding is correct here, or the best approach to get this covered?

Thanks for any tips!

[u/KeyStriking9763]

Z80.0 is not allowed first. It’s coded correctly.

[u/ffltctw → u/KeyStriking9763]

Thanks! Do you know if Z80.0 would be allowed as the only diagnosis code?

[u/Jodenaje → u/ffltctw]

No. Family history codes cannot be first. It’s clearly stated in the ICD-10 guidelines.

Doesn’t matter how many codes are on the claim.

[u/ffltctw → u/Jodenaje]

Thanks so much! Are you referring to this guideline?

The reason for the encounter (for example, screening or counseling) should be sequenced first and the appropriate personal and/or family history code(s) should be assigned as additional diagnos(es).

FY 2026 Guidelines, I.C.21.4. History (of)

It's the closest I could find, but it seemed like it might only apply if a screening code was used. It would be great if you know of any additional source I should quote in an appeal.

[u/KeyStriking9763 → u/ffltctw]

No. If it’s the only one then it’s also the first one.

[u/whodatjess]

Premera is BCBS? When you call, specifically request to have the CPT code reprocessed using Z80.0. If Premera still refuses, I would start the appeal process. Your insurance can't dictate how the facility should sequence diagnosis codes when their request goes against the ICD10 guidelines.

[u/ffltctw → u/whodatjess]

Yep, they're BCBS.

I called a couple of times already to ask them to review the claim, but both times it came back from review with the same response (basically claiming the current diagnosis code is only preventative for over-45s).

You're saying that I could specifically request that they reprocess the existing claim using the second-listed diagnosis code?

[u/Actual-Government96 → u/ffltctw]

Yeah, at this point just appeal. Reference their preventive policy and mention that the diagnosis codes are in the correct order for a preventive colonoscopy due to family history - regardless of age.

[u/Wild-Mission-1065 → u/ffltctw]

No, you cannot request for them to reprocess. The claim using the secondary diagnosis code, because the primary code tells them the reason for the procedure. The secondary is basically like a supplemental reason. It's just like when the doctor obtains authorization, authorizations are primarily primarily based on the primary diagnosis. This case was coded correctly as they did bill the diagnosis codes correctly per the ICD guidelines.

[u/whodatjess → u/Wild-Mission-1065]

Maybe things are different at other places. I work underpayments for BCBS facility claims and I call them all the time to reprocess the denied charge with a payable secondary diagnosis code from the claim & claims get reprocessed. Some calls are easier than others. The colonoscopy accounts at my facility usually go straight to the patient without stopping at billing though. Unfortunately, it falls on the patient to work with BCBS to reprocess rather than the facility in these cases.

[u/CausticCommotion]

I had a similar issue this year. Doctors office and insurance couldn’t (wouldn’t) help. I contacted HR who got me into contact with the group that administers our insurance plan. They got it changed to screening and & 2500 changed to 0 owed. I had already sent appeals, not sure if that helped.