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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 say that 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. Excicision 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 rule in Local Coverage Determination (LCD) - Colonoscopy and Sigmoidoscopy - Diagnostic
(L34614) - Effective October 1, 2020.
The rules say that a diagnostic colonoscopy is not considered medically necessary for the following conditions:
1. 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.
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 Crohn's colitis, 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.
You can find this rule in Local Coverage Determination (LCD) - Colonoscopy and Sigmoidoscopy - Diagnostic
(L34614) - Effective October 1, 2020.
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.