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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 gastrointestinal (GI) source has been excluded, 
c. Presence of fecal occult blood, 
d. Positive stool Deoxyribonucleic Acid (DNA) test results.  
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 
7. Intraoperative identification of the site of a lesion that cannot be detected by palpation or gross 
inspection at surgery 
8. Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasm, and 
polypectomy site 
9. Removal of foreign body. 
10. Excision of colonic polyps. 
11. Decompression of acute nontoxic megacolon or sigmoid volvulus, pseudo obstruction of the colon 
(Ogilvies syndrome). 
12. Balloon dilatation of stenotic lesions 
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 Crohns 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). 
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 information in the Local Coverage Determination (LCD) for Colonoscopy and 
SigmoidoscopyDiagnostic (L34614). 
 
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.