Diagnostic and Therapeutic Colonoscopy

Colonoscopy is covered when clinically indicated for diagnostic evaluation of radiology-detected colonic lesions, abnormal colorectal screening tests, unexplained GI bleeding, positive FOBT, unexplained iron deficiency anemia, suspected or known IBD when management will change, acute colonic ischemia, Streptococcus bovis endocarditis with likely colonic source, intraoperative lesion localization, and for therapeutic interventions (hemostasis, polypectomy, dilation, decompression, foreign body removal, endoscopic perforation repair when appropriate). Colonoscopy is not covered for routine screening in asymptomatic patients with only family history (screening rules apply), chronic stable IBS, acute limited diarrhea, hemorrhoids, routine preoperative exams for noncolonic surgery, demonstrated upper GI bleeding source, or when contraindications exist (fulminant colitis, acute severe diverticulitis, suspected perforated viscus except in limited endoscopic-repair situations). Documentation must support the indication (radiology reports, abnormal screening/stool test results, FOBT, EGD reports, labs such as CBC/iron studies or ESR, prior colonoscopy/genetic reports, operative reports, and endoscopist credentials when repair is contemplated).