Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

LCD Information Document Information Source LCD ID N/A LCD ID L34005 Original ICD-9 LCD ID Not Applicable LCD Title Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy Proposed LCD in Comment Period N/A Source Proposed LCD N/A Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 01/22/2026 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 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Issue Issue Description This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity. Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Code of Federal Regulations: 42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter). CMS Publications:CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12: CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12: 20.4.6 Payment due to unusual circumstances (Modifiers 22 and 52) CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 18: 60.2 Colorectal Cancer Screening HCPCS Codes, Frequency Requirements, and Age Requirements (If Applicable) Coverage Indications, Limitations, and/or Medical Necessity Abstract: This LCD addresses the colonoscopies that are NOT performed for colorectal cancer screening. Colorectal cancer screening is a separate benefit with specific guidelines.Proctosigmoidoscopy is the examination of the rectum and sigmoid colon. Sigmoidoscopy is the examination of the entire rectum, sigmoid colon and may include examination of a portion of the descending colon. Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum. The colonoscope is inserted anally (or through a stoma) and is advanced optimally through the large intestine under direct vision, using the scope's optical system. Indications: The following are Medicare-covered indications: Evaluation of an abnormality discovered on barium enema and/or other imaging technique that is likely to be clinically significant, such as a filling defect or stricture or an inadequate examination; Evaluation of unexplained gastrointestinal bleeding: Hematochezia not thought to be from rectum or perianal source Melena of unknown origin; Presence of fecal occult blood Unexplained iron deficiency anemia; Surveillance of colonic neoplasia. When the patient has a history of colorectal cancer or polyps and is being followed for this indication; Examination to evaluate entire colon for synchronous cancer or polyps in a patient with treatable cancer or polyp; Follow-up in one year after surgery for treatment of colorectal cancer; This patient is identified as being at high-risk for colon cancer and is eligible for continued screening at 24-month intervals. Follow-up for removal of neoplastic polyp (follow-up at least three to six months to verify removal of large sessile adenoma [i.e., greater than 2 cm in greatest dimension] after colonoscopic removal); This patient is identified as being at high-risk for colon cancer and is eligible for continued screening at 24-month intervals. 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: Pancolitis of greater than seven years duration; or, Left-sided colitis of over 15 years duration (no surveillance needed for disease limited to rectosigmoid); Chronic inflammatory bowel disease of the colon if a more precise diagnosis or if a determination of the extent of activity of disease will influence immediate management; Clinically significant diarrhea of unexplained origin with additional findings (e.g., with weight loss or negative stool cultures persisting for more than 3 weeks; Intraoperative identification of the site of a lesion that can not be detected by palpation or gross inspection at surgery (e.g., polypectomy site or location of a bleeding source); Evaluation of acute colonic ischemia/ischemic bowel disease; Evaluation of patient with Streptococcus bovis endocarditis; Treatment of bleeding from such lesions as vascular anomalies, ulceration and neoplasia; Removal of foreign body; Excision of colonic polyps; Decompression of pseudo-obstruction of the colon (Olgilvie’s syndrome); Treatment of sigmoid volvulus or stricture; Evaluation of unexplained, new onset constipation, refractory to medical therapy; Evaluation of anorectal polyp (adenomatous polyp only); or, Palliative treatment of stenosing, bleeding neoplasms (e.g., laser, electrocoagulation, stenting). Limitations: Endoscopy is generally not covered for treating the following, and records must have additional documentation indicating the medical necessity of the procedure for review as needed: Chronic, stable, irritable bowel syndrome, or chronic abdominal pain, There are unusual exceptions in which colonoscopy may be done to rule out organic disease, especially if symptoms are unresponsive to therapy; Acute diarrhea; Hemorrhoids; Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms when it will not influence management; Routine follow-up of inflammatory bowel disease (except for cancer surveillance in Crohn’s disease and chronic ulcerative colitis); Routine examination of the colon in patients about to undergo elective abdominal surgery for non-colonic disease; Upper gastrointestinal (GI) bleeding or melena with a demonstrated upper GI source; or, Bright red rectal bleeding with a convincing anorectal source on sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source; Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy is generally not covered for: Fulminant colitis; Possible perforated viscus; Acute severe diverticulitis; or, Diverticulosis. This condition is not usually considered an indication for diagnostic or therapeutic colonoscopy, sigmoidoscopy or proctosigmoidoscopy, but may be reported on the claim when this condition is found to be the final diagnosis. Other Comments: For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC. to process their claims.Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A

Abstract: This LCD addresses the colonoscopies that are NOT performed for colorectal cancer screening. Colorectal cancer screening is a separate benefit with specific guidelines. Proctosigmoidoscopy is the examination of the rectum and sigmoid colon. Sigmoidoscopy is the examination of the entire rectum, sigmoid colon and may include examination of a portion of the descending colon. Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum. The colonoscope is inserted anally (or through a stoma) and is advanced optimally through the large intestine under direct vision, using the scope's optical system. Indications: The following are Medicare-covered indications: Evaluation of an abnormality discovered on barium enema and/or other imaging technique that is likely to be clinically significant, such as a filling defect or stricture or an inadequate examination; Evaluation of unexplained gastrointestinal bleeding: Hematochezia not thought to be from rectum or perianal source Melena of unknown origin; Presence of fecal occult blood Unexplained iron deficiency anemia; Surveillance of colonic neoplasia. When the patient has a history of colorectal cancer or polyps and is being followed for this indication; Examination to evaluate entire colon for synchronous cancer or polyps in a patient with treatable cancer or polyp; Follow-up in one year after surgery for treatment of colorectal cancer; This patient is identified as being at high-risk for colon cancer and is eligible for continued screening at 24-month intervals. Follow-up for removal of neoplastic polyp (follow-up at least three to six months to verify removal of large sessile adenoma [i.e., greater than 2 cm in greatest dimension] after colonoscopic removal); This patient is identified as being at high-risk for colon cancer and is eligible for continued screening at 24-month intervals. 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: Pancolitis of greater than seven years duration; or, Left-sided colitis of over 15 years duration (no surveillance needed for disease limited to rectosigmoid); Chronic inflammatory bowel disease of the colon if a more precise diagnosis or if a determination of the extent of activity of disease will influence immediate management; Clinically significant diarrhea of unexplained origin with additional findings (e.g., with weight loss or negative stool cultures persisting for more than 3 weeks; Intraoperative identification of the site of a lesion that can not be detected by palpation or gross inspection at surgery (e.g., polypectomy site or location of a bleeding source); Evaluation of acute colonic ischemia/ischemic bowel disease; Evaluation of patient with Streptococcus bovis endocarditis; Treatment of bleeding from such lesions as vascular anomalies, ulceration and neoplasia; Removal of foreign body; Excision of colonic polyps; Decompression of pseudo-obstruction of the colon (Olgilvie’s syndrome); Treatment of sigmoid volvulus or stricture; Evaluation of unexplained, new onset constipation, refractory to medical therapy; Evaluation of anorectal polyp (adenomatous polyp only); or, Palliative treatment of stenosing, bleeding neoplasms (e.g., laser, electrocoagulation, stenting). Limitations: Endoscopy is generally not covered for treating the following, and records must have additional documentation indicating the medical necessity of the procedure for review as needed: Chronic, stable, irritable bowel syndrome, or chronic abdominal pain, There are unusual exceptions in which colonoscopy may be done to rule out organic disease, especially if symptoms are unresponsive to therapy; Acute diarrhea; Hemorrhoids; Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms when it will not influence management; Routine follow-up of inflammatory bowel disease (except for cancer surveillance in Crohn’s disease and chronic ulcerative colitis); Routine examination of the colon in patients about to undergo elective abdominal surgery for non-colonic disease; Upper gastrointestinal (GI) bleeding or melena with a demonstrated upper GI source; or, Bright red rectal bleeding with a convincing anorectal source on sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source; Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy is generally not covered for: Fulminant colitis; Possible perforated viscus; Acute severe diverticulitis; or, Diverticulosis. This condition is not usually considered an indication for diagnostic or therapeutic colonoscopy, sigmoidoscopy or proctosigmoidoscopy, but may be reported on the claim when this condition is found to be the final diagnosis. Other Comments: For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC. to process their claims. Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC. Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.