Indications and Limitations of Coverage and/or Medical Necessity
Colonoscopy is a visual examination of the lining of the large intestine with a flexible fiberoptic endoscope. The colonoscope is inserted anally and is advanced through the large intestine under direct vision, using the scope's optical system.
Proctosigmoidoscopy is the endoscopic examination of the lining of the distal sigmoid colon, the rectum, and the anal canal. A flexible sigmoidoscope is inserted into the anus, to allow visualization of the distal sigmoid colon, rectum, and descending colon.
Indications and Limitations of Coverage
Colonoscopy is a covered procedure when used for the following indications:
1. Evaluation of an abnormality on barium enema that is likely to be clinically - significant, such as a filling defect or stricture;
2. Evaluation of unexplained gastrointestinal bleeding;
a. Hematochezia not thought to be from rectum or perianal source;
b. Melena of unknown origin; or
c. Presence of fecal occult blood;
3. Unexplained iron deficiency anemia;
4. Surveillance of colonic neoplasia;
a. Examination to evaluate entire colon for synchronous cancer or neoplastic polyps in a patient with treatable cancer or neoplastic polyp;
b. Follow-up in 1 year, then 3-5 year intervals following resection of colorectal cancer or neoplastic polyp;
c. In patients with Crohn's colitis and chronic ulcerative colitis; colonoscopy every one or two years with multiple biopsies for detection of cancer and dysplasia in patients with:
i. Pancolitis of greater than seven years duration; or
ii. Left-sided colitis of over 15 years duration (no surveillance needed for disease limited to rectosigmoid);
5. Chronic inflammatory bowel disease of the colon if more precise diagnosis or termination of the extent of activity of disease will influence immediate management clinically significant diarrhea of unexplained origin with additional symptoms (e.g., weight loss);
6. Clinically significant diarrhea of unexplained origin with additional symptoms (e.g., weight loss);
7. Intraoperative identification of the site of a lesion that cannot be detected by palpitation or gross inspection at surgery (e.g., polypectomy site or location of a bleeding source);
8. Evaluation of acute colonic ischemia/ischemic bowel disease;
9. Evaluation of patient with Streptococcus bovis endocarditis;
10. Treatment of bleeding from such lesions as vascular anomalies, ulceration and neoplasia;
11. Removal of foreign body;
12. Excision of colonic polyps;
13. Decompression of pseudo-obstruction of the colon (Ogilvie's syndrome); or
14. Treatment of sigmoid volvulus.
Colonoscopy is generally not covered for treating the following:
1. Chronic, stable, irritable bowel syndrome or chronic abdominal pain. There are unusual exceptions in which colonoscopy may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy;
2. Acute limited diarrhea;
3. Hemorrhoids;
4. Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms when it will not influence management;
5. Routine follow-up of inflammatory bowel disease (except for cancer surveillance in chronic ulcerative colitis);
6. Routine examination of the colon in patients about to undergo elective abdominal surgery for non-colonic disease;
7. Upper GI bleeding or melena with a demonstrated upper GI source;
8. Bright red rectal bleeding in patient with a convincing anorectal source on sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source; or
9. Patients with a strong positive family history without a personal history of symptoms.
Colonoscopy is generally not indicated for:
1. Fulminant colitis;
2. Possible perforated viscus; or
3. Acute severe diverticulitis.
Flexible Sigmoidoscopy is a covered procedure when used for the following indications:
1. Follow-up for neoplasia previously treated by flexible sigmoidoscopy;
2. Surveillance for neoplasia in patients with subtotal colectomy for cancer or ileoproctostomy for familial polyposis;
3. Evaluation of lower GI symptoms in conjunction with barium enema xrays;
4. Evaluation of a rectosigmoid stricture demonstrated on a high quality barium xray;
5. Acute colitis; and
6. Anorectal symptoms (e.g., bleeding, pain, itching).
Flexible Sigmoidoscopy is generally not covered for treating the following:
1. When diagnostic colonoscopy is indicated (see above);
2. When diagnostic colonoscopy is not considered medically necessary or contraindicated (see above);
3. Constipation (new or chronic) without attempt at treatment;
4. Possible perforated viscus; or
5. Severe acute diverticulitis.
CMS National Coverage Policy:
-Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical checkups.
-Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury.
1. Claims for indications that are generally not covered must be submitted with supporting documentation indicating the medical necessity of the procedure.
2. The medical record should support the medical necessity and frequency of this treatment.
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