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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that [summarize the applicable rule/regulation]the following are Medicare-covered indications for diagnostic colonoscopy:
1. Evaluation of an abnormality on barium enema or other imaging study, which is likely to be clinically significant, such as filling a 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; after an upper GI source has been excluded,
c. Presence of fecal occult blood,
d. Positive stool DNA test results. (e.g. guaiac/Fecal immunochemical test {FIT Test}/Cologuard).
3. Unexplained iron deficiency anemia.
4. Examination to evaluate entire colon for synchronous cancer or polyps in a patient with treatable cancer or polyp.
5. Chronic inflammatory bowel disease of the colon if more precise diagnosis or determination of the extent of activity of disease will influence immediate management.
6. Clinically significant diarrhea of unexplained origin with additional symptoms (e.g., with weight loss).
7. Intraoperative identification of the site of a lesion that cannot be detected by palpation or gross inspection at surgery (e.g., polypectomy site or location of a bleeding source).
8. Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasm, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy).
9. Removal of foreign body.
10. Excision of colonic polyps.
11. Decompression of acute nontoxic megacolon or sigmoid volvulus, pseudo obstruction of the colon (Ogilvie's syndrome).
12. Balloon dilatation of stenotic lesions (e.g., anastomotic strictures).
13. Palliative treatment of stenosing or bleeding neoplasm.
14. Marking a neoplasm for localization.
15. Evaluation of a patient with endocarditis due to streptococcus bovis or any bacterium of enteric origin.
16. Suspected disease of terminal ileum.
17. Evaluation of acute colonic ischemia/ischemic bowel disease.
18. 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:
a. Pancolitis of eight or more years duration; or
b. Left-sided colitis of 15 or more years duration.
19. 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, repeat colonoscopy yearly.
20. Patients undergoing curative resection for colon or rectal cancer should undergo a colonoscopy 1 year after the resection (or 1 year following the performance of the colonoscopy that was performed to clear the colon of synchronous disease).
You can find this information in Local Coverage Determination (LCD): Colonoscopy and Sigmoidoscopy-Diagnostic (L34614).
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).
The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.