Diagnostic and Therapeutic Colonoscopy
L36868
Covered: diagnostic and therapeutic colonoscopy is allowed for suspected or known IBD when extent affects management, surveillance for colonic neoplasia or high‑risk IBD per CMS/guidelines, evaluation of unexplained GI bleeding (FOBT, iron‑deficiency anemia, melena after upper GI ruled out, non‑rectal hematochezia), unexplained significant diarrhea, acute colonic ischemia, S. bovis endocarditis evaluation, abnormal radiology/oncology/stool‑DNA findings, intraoperative localization and therapeutic procedures (polypectomy, bleeding control, dilation, decompression, foreign body removal, and endoscopic repair when it will avoid further surgery); not covered are routine pre‑op for noncolonic disease, chronic stable IBS, acute limited diarrhea, hemorrhoids‑only findings, routine IBD follow‑up except specified, bleeding with a demonstrated upper‑GI source, bright red rectal bleeding with a convincing anorectal source, family history alone (screening covered separately), and it is contraindicated in fulminant colitis and acute severe diverticulitis (suspected perforation generally contraindicated unless endoscopic repair feasible). Key requirements: the procedure must be capable of examining the colon proximal to the splenic flexure and potentially reaching the cecum, follow surveillance intervals (typically 1 year then 3–5 years after polypectomy/CRC as applicable), and documentation must substantiate medical necessity (including chronicity/therapy tried for abdominal pain), record maximum depth, findings and interventions, and be available to Medicare on request (office scopes’ make/model/serial number must be kept).