Diagnostic Colonoscopy

Jurisdiction: JH MAC Part B. States: Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas. Type: Active LCD

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits. History/Background and/or General Information Colonoscopy allows direct visual examination of the intestinal tract with a flexible tube containing light transmitting glass fibers that return a magnified image. Colonoscopy can act as both a diagnostic and therapeutic tool in the same procedure. Therapeutic indications include removal of polyps or foreign bodies, hemostasis by coagulation, and removal of tumors. Covered Indications A diagnostic colonoscopy will be considered medically reasonable and necessary under any of the following circumstances: Evaluation of an abnormality (e.g. barium enema), which is likely to be clinically significant, such as a filling defect or stricture. 1 Evaluation and excision of polyps detected by barium enema or flexible sigmoidoscopy, computed tomography (CT), ultrasound, magnetic resonance imaging (MRI), and positron emission tomography (PET). 2 Evaluation of unexplained gastrointestinal bleeding; hematochezia not thought to be from rectum or perianal source, melena of unknown origin, or presence of fecal occult blood. 1 Unexplained iron deficiency anemia. 1 Examination to evaluate the entire colon for simultaneous cancer or neoplastic polyps in a patient with a treatable cancer or neoplastic polyp. 1 The term treatable cancer may include not only curative intent, but also procedures done to prolong survival, progression free disease, and quality of life/palliative care. Evaluation of a patient with carcinoma of the colon before bowel resection. Post-surgical colonoscopy should be conducted at 1 year, if normal then subsequent examination should be at 3 years, if normal then subsequent examination should be at 5 years. 1,4 Yearly evaluation with multiple biopsies for detection of cancer and dysplasia in patients with chronic ulcerative colitis who have had pancolitis of greater than seven years duration. 4 Yearly evaluation with multiple biopsies for detection of cancer and dysplasia in patients with chronic ulcerative colitis who have had left-sided colitis of over 15 years duration. 4 Evaluation in patients with chronic inflammatory bowel disease of the colon when more precise diagnosis or determination of the extent of activity of disease will influence immediate management. 1,4 Evaluation of clinically significant diarrhea of unexplained origin. 1 Evaluation and treatment of bleeding from lesions such as vascular anomalies, ulceration, neoplasia, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy). 1,3 Detection and removal of foreign bodies. 1 Evaluation and decompression treatment of acute non-toxic megacolon. 1 Evaluation and balloon dilation treatment of stenotic lesions (e.g., anastomotic strictures). 1 Evaluation and decompression of colonic volvulus. 1 Examination and evaluation when a change in management is probable or is being suspected based on results of the colonoscopy. 1 Evaluation within 6 months of the removal of sessile polyps to determine and document total excision. If evaluation indicates that residual polyp is present, excision should be done with repeat colonoscopy within 6 months. After evidence of total excision without return of the polyp. Unsuccessful colonoscopy preoperatively due to obstructive cancer, repeat colonoscopy 3-6 months post-operatively unless unresectable metastases are found at surgery. 4 Evaluation to differentiate between ulcerative and Crohn's colitis. 1 Evaluation 3 years after resection of newly diagnosed small ( After 1 negative 3-year follow-up examination subsequent surveillance intervals may be increased to 5 years. 4 Evaluation at 1 and 4 year intervals after resection of multiple or large (> 10mm) adenomatous polyps. Subsequent surveillance intervals may then be increased to every 5 years. 4 Evaluation in 1 year after the removal of multiple adenomas. If examination proves negative then repeat in 3 years. After 1 negative 3-year follow-up examination, repeat exam every 5 years. 2 Evaluation of a patient presenting with signs/symptoms (e.g., rectal bleeding, abdominal pain) of a disorder that appears to be related to the colon. 1 Limitations Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD. Diagnostic colonoscopy is not indicated in patients with chronic ulcerative colitis who have had left-sided colitis of over 15 years duration when disease is limited to the rectosigmoid colon.