Diagnostic Colonoscopy

Diagnostic colonoscopy is covered when clinically indicated for evaluation of imaging abnormalities, polyp detection/removal, unexplained gastrointestinal bleeding or iron deficiency anemia, preoperative assessment for colon carcinoma, suspected colonic disease causing symptoms, and for therapeutic interventions (polypectomy, hemostasis, dilation, decompression, foreign body removal). Specific surveillance intervals are required for post-surgical evaluation, ulcerative colitis surveillance (annual after defined disease durations), and adenoma follow-up (1, 3, 4, and 5-year patterns depending on polyp number/size); services must meet CMS medical necessity requirements and appropriate documentation. Colonoscopy is not indicated for left-sided ulcerative colitis >15 years duration if disease is limited to the rectosigmoid colon; claims are subject to post-payment review and medical audit.

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