Screening Colonoscopy Guidelines

Screening colonoscopy is covered for average‑risk asymptomatic individuals every 10 years from age 45 through 85 (excluding those with prior colorectal cancer, colonic adenomas, or colonic inflammatory bowel disease), while high‑risk patients (per family‑history criteria, advanced serrated lesions, or hereditary syndromes) require earlier and/or more frequent colonoscopy per the guideline schedules (e.g., family‑history: start 10 years younger than the youngest affected first‑degree relative or at age 40 and repeat every 5 years in qualifying scenarios). Requests must include pertinent medical records and a recent clinical evaluation (telehealth acceptable for established patients); insufficient documentation, non–evidence‑based or data‑collection procedures, and requests outside guideline criteria will not be approved.

"A pertinent clinical evaluation since the new onset or change in symptoms is required prior to considering gastrointestinal endoscopy services; absence of such evaluation is a basis for non-approval."