CG-SURG-01 Colonoscopy

This policy addresses colonoscopy for colorectal cancer screening, surveillance, and diagnostic evaluation. It is medically necessary for screening in average-risk, asymptomatic individuals (no personal history of adenomas, sessile serrated polyps, colorectal cancer, inflammatory bowel disease, or cystic fibrosis, and no family history of colorectal cancer) starting at age 45 and every 10 years thereafter, and for a 10-year follow-up after removal of a hyperplastic (non-SSP) polyp <1 cm limited to the rectum/sigmoid. It is not medically necessary for other screening/surveillance or diagnostic indications not listed, including chronic stable irritable bowel syndrome, chronic abdominal pain, acute diarrhea, routine IBD follow-up (except cancer surveillance in chronic ulcerative colitis and Crohn’s colitis), or evaluation of upper GI bleeding/melena with a known upper GI source.

"Screening Colonoscopy in Average RiskPopulations(that is, asymptomatic individuals without specific risk factors including no personal history of adenomas, sessile serrated polyps [SSPs], colorecta..."