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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 A diagnostic colonoscopy is indicated for the following: 
 Evaluation of an abnormality discovered by a radiology examination wherein the findings of the study 
are consistent with a colonic lesion that is likely to be clinically significant, 
 An abnormal oncology colorectal screening or stool based DNA test as described in the CMS 
Colorectal Cancer screening Preventive Services requirements, 
 Evaluation of unexplained gastrointestinal bleeding: 
o Hematochezia that is not from the rectum or a perianal source, 
o Melena of unknown origin after an upper GI source has been ruled out or when clinical findings 
indicate that a lower GI source may also be present, 
o Presence of fecal occult blood, or 
o Unexplained iron deficiency anemia. 
 Clinically significant diarrhea of unexplained origin, after other appropriate workup, 
 Evaluation of acute colonic ischemia/ischemic bowel disease, 
 Evaluation of patients with streptococcus bovis endocarditis when a source is determined to likely to be 
of colonic origin (e.g. streptococcus bovis), 
 Clinical suspicion of inflammatory bowel disease which may be manifested by abdominal pain, fever, 
diarrhea, bloody diarrhea, elevated erythrocyte sedimentation rate or other pertinent findings, 
 Known chronic inflammatory bowel disease of the colon when a more precise determination of the 
extent of disease will influence clinical management, 
 Surveillance of selected patients with Crohns colitis, or chronic ulcerative colitis for the purpose of 
ruling out colorectal cancer is considered high risk screening and should follow the requirements set 
forth in the CMS Internet Only Manual 100-04 Chapter 18 Section 60 
You can find this rule in the Medicare Local Coverage Determination (LCD)- L34213, Diagnostic and 
Therapeutic Colonoscopy. 
 
The rules say that effective for services furnished on or after July 1, 2001, screening colonoscopies (code 
G0121) are covered when performed under the following conditions: 
 
1. On individuals not meeting the criteria for being at high risk for developing colorectal cancer (refer to 
280.2.3); 2. At a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which 
the last covered G0121 screening colonoscopy was performed); and 
 
3. If the individual would otherwise qualify to have covered a G0121 screening colonoscopy based on the 
above (see 280.2.2.D.1 and 2) but has had a covered screening flexible sigmoidoscopy (code G0104), then 
the individual may have a covered G0121 screening colonoscopy only after at least 47 months have passed 
following the month in which the last covered G0104 flexible sigmoidoscopy was performed. 
 
You can find this rule in the Medicare Benefit Policy Manual Chapter 15  Covered Medical and Other Health 
Services280.2.2 - Coverage Criteria (Rev. 196, Issued: 10-17-14, Effective: 01-27-14, Implementation: 11-18-
14), D. Screening Colonoscopies Performed on Individuals Not Meeting the Criteria for Being at High-Risk for 
Developing Colorectal Cancer (Code G0121). 
 
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