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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 contract says for people at high risk of colorectal cancer, we cover a screening colonoscopy (or screening 
barium enema as an alternative) every 24 months. You can find this information on page 57 of the Plan's 2023 
Evidence of Coverage. 
 
The rules say that 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: 
Hematochezia that is not from the rectum or a perianal source, 
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, 
Presence of fecal occult blood, or 
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 
Surveillance of colonic neoplasia: 
Evaluation of the entire colon for a cancer with polyps noted on an earlier colonoscopy in accordance with the established national guidelines. 
This includes patients with known polyps from a previous colonoscopy or imaging study who have a known 
genetic predisposition for colon cancer. 
Intraoperative identification of the site of a lesion for findings that are suspected but that cannot be 
confirmed/detected by palpation or gross inspection at surgery. 
Diagnostic colonoscopy is not covered for evaluation of the following: 
 
Chronic, stable irritable bowel syndrome, 
Acute limited diarrhea, 
Hemorrhoids, 
Metastatic adenocarcinoma of unknown primary site when a colonic origin is strongly suspected based on 
history and physical and imaging findings or biopsy reports, 
Routine follow-up of inflammatory bowel disease (except as indicated above in this section), 
Routine examination of the colon in patients about to undergo elective abdominal surgery for noncolonic 
disease, 
Upper GI bleeding or melena with a demonstrated upper GI source and absence of findings suggestive of a 
lower GI bleeding site, 
Bright red rectal bleeding in patients with a convincing anorectal source via direct examination, anoscopy, or 
sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source, 
Patients with a family history of colon cancer without a personal history of symptoms. These patients may be 
covered by the CMS Colorectal Screening coverage. 
A therapeutic colonoscopy is indicated for: 
 
Treatment of bleeding from such lesions as vascular anomalies, ulceration, and neoplasia, 
Balloon dilation of a stenotic lesion, 
Decompression of a sigmoid volvulus and/or an acute non-toxic megacolon or pseudo-obstruction associated 
with Ogilvies Syndrome 
Removal of foreign body, 
Excision of colonic polyps. 
Repair of a perforation when it is expected that such repair will most likely avoid further surgical intervention 
and further surgical intervention is not needed (for example to drain an abscess at which time the perforation 
could be corrected by the surgeon) 
Colonoscopy is contraindicated if the patient has: 
 
Fulminant colitis, 
Acute severe diverticulitis, or 
Suspected perforated viscus. A therapeutic colonoscopy by a trained endoscopist capable of repairing a 
perforation site may be allowed when the clinical findings and imaging studies strongly indicate that a 
perforation has occurred and the suspected site of the perforation allows for endoscopic repair. 
The medical records must support the medical reasonableness, necessity, and frequency of each diagnostic 
service supplied. 
 
You can find this information in the Local Coverage Determination (LCD) for Diagnostic and Therapeutic 
Colonoscopy (L34213). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.