Diagnostic and Therapeutic Colonoscopy Guidelines

EviCore covers diagnostic and therapeutic colonoscopy for specified indications—including screening and detailed surveillance after polypectomy (intervals based on polyp histology, size, number and resection method), IBD surveillance and management, bleeding, and other therapeutic uses—but excludes colonoscopy for isolated constipation, most acute diarrhea in immunocompetent patients, metastatic adenocarcinoma of unknown primary when results won’t alter management, and contraindicates it in fulminant colitis, acute severe diverticulitis, or suspected perforation. Approval requires submission of pertinent medical records and a recent clinical evaluation (history/physical, relevant labs, imaging, pathology/procedure reports), documentation of polyp size/number/histology and prior BBPS for inadequate prep, and completion of specified pre-testing (stool studies, fecal calprotectin/CRP, celiac serology, etc.) with adherence to the guideline’s age- and interval-based recommendations.