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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 will be considered medically reasonable and necessary under any 
of the following circumstances: 
1. Evaluation of an abnormality (e.g., barium enema), which is likely to be clinically significant, such as a 
filling defect or stricture. 
2. Evaluation and excision of polyps detected by barium enema or flexible sigmoidoscopy, computed 
tomography (CT), ultrasound, magnetic resonance imaging (MRI), and positron emission tomography 
(PET). 
3. Evaluation of unexplained gastrointestinal bleeding; hematochezia not thought to be from rectum or 
perianal source, melena of unknown origin, or presence of fecal occult blood. 
4. Unexplained iron deficiency anemia. 
5. Examination to evaluate the entire colon for simultaneous cancer or neoplastic polyps in a patient with a 
treatable cancer or neoplastic polyp. The term treatable cancer may include not only curative intent, but 
also procedures done to prolong survival, progression free disease, and quality of life/palliative care. 
6. Evaluation of a patient with carcinoma of the colon before bowel resection. 
 Post-surgical colonoscopy should be conducted at 1 year, if normal then subsequent examination 
should be at 3 years, if normal then subsequent examination should be at 5 years. 
7. Yearly evaluation with multiple biopsies for detection of cancer and dysplasia in patients with chronic 
ulcerative colitis who have had pancolitis of greater than seven years duration. 
8. Yearly evaluation with multiple biopsies for detection of cancer and dysplasia in patients with chronic 
ulcerative colitis who have had left-sided colitis of over 15 years duration. 
9. Evaluation in patients with chronic inflammatory bowel disease of the colon when more precise 
diagnosis or determination of the extent of activity of disease will influence immediate management. 
10. Evaluation of clinically significant diarrhea of unexplained origin. 
11. Evaluation and treatment of bleeding from lesions such as vascular anomalies, ulceration, neoplasia, 
and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy). 12. Detection and removal of foreign bodies. 
13. Evaluation and decompression treatment of acute non-toxic megacolon. 
14. Evaluation and balloon dilation treatment of stenotic lesions (e.g., anastomotic strictures). 
15. Evaluation and decompression of colonic volvulus. 
16. Examination and evaluation when a change in management is probable or is being suspected based on 
results of the colonoscopy. 
17. 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. 
18. Unsuccessful colonoscopy preoperatively due to obstructive cancer, 
 repeat colonoscopy 3-6 months post-operatively unless unresectable metastases are found at 
surgery. 
19. Evaluation to differentiate between ulcerative and Crohn's colitis. 
20. Evaluation 3 years after resection of newly diagnosed small (< 5mm diameter) adenomatous polyps 
when only a single polyp was detected. 
 After 1 negative 3-year follow-up examination subsequent surveillance intervals may be 
increased to 5 years. 
21. Evaluation at 1- and 4-year intervals after resection of multiple or large (> 10mm) adenomatous polyps. 
 Subsequent surveillance intervals may then be increased to every 5 years. 
22. Evaluation in 1 year after the removal of multiple adenomas. 
 If examination proves negative, then repeat in 3 years. 
 After 1 negative 3-year follow-up examination, repeat exam every 5 years. 
23. Evaluation of a patient presenting with signs/symptoms (e.g., rectal bleeding, abdominal pain) of a 
disorder that appears to be related to the colon. 
 
Limitations 
 
Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in 
this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and 
all existing CMS national coverage determinations, and all Medicare payment rules. 
 
The redetermination process may be utilized for consideration of services performed outside of the reasonable 
and necessary requirements in this LCD. 
1. Diagnostic colonoscopy is not indicated in patients with chronic ulcerative colitis who have had left-
sided colitis of over 15 years duration when disease is limited to the rectosigmoid colon. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L38812: Diagnostic Colonoscopy. 
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.