Patients with a family history of colon cancer without a personal history of symptoms
Local Coverage Determination (LCD): Diagnostic Colonoscopy (L34213)
Coverage Indications, Limitations, and/or Medical Necessity
Colonoscopy is a visual examination of the lining of the large intestine using a rigid or flexible video or fiberoptic endoscope. The procedure includes inspection of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum. A colonoscopy, by definition, must examine the colon proximal to the splenic flexure. The colonoscope is inserted via the anus or stoma, and then advanced under direct vision or video image. A rigid sigmoidoscope may be used for an intraoperative transcolotomy approach.
A colonoscopy requires the use of an instrument that has the potential to examine the entire colon, and must potentially reach the entire colon (i.e. the cecum).
Do not report a colonoscopy procedure code for an endoscopy performed with a sigmoidoscope on a patient with a normal length colon, even if the sigmoidoscope reaches proximal to the splenic flexure. A sigmoidoscope (an endoscope typically 65 centimeters in length) may be used for a colonoscopy only if the bowel is sufficiently short so that the entire colon may be examined.
A
diagnostic colonoscopy is
indicated for the following:
Evaluation of an abnormality discovered by a barium enema that is likely to be clinically significant, such as a filling defect or a stricture,
Evaluation of unexplained gastrointestinal bleeding:
Hematochezia that is not from the rectum or a perianal source,
Melena of unknown origin, or
Presence of fecal occult blood
Unexplained iron deficiency anemia,
Surveillance of colonic neoplasia:
Evaluation of the entire colon for a synchronous cancer or polyps in a patient with treatable cancer or polyps,
Surveillance of selected patients with Crohn’s colitis, or chronic ulcerative colitis. Suitable candidates are those with:
Pancolitis of greater than seven years duration, or
Left-sided colitis of over 15 years duration,
Chronic inflammatory bowel disease of the colon when a more precise determination of the extent of disease will influence management,
Clinically significant diarrhea of unexplained origin,
Intraoperative identification of the site of a lesion that cannot be detected by palpation or gross inspection at surgery,
Evaluation of acute colonic ischemia/ischemic bowel disease,
Evaluation of patients with streptococcus bovis endocarditis,
Treatment of bleeding from such lesions as vascular anomalies, ulceration, and neoplasia,
Removal of foreign body,
Excision of colonic polyps,
Decompression of pseudo-obstruction of the colon (Ogilvies’ Syndrome),
Treatment of sigmoid volvulus,
Suspected disease of terminal ileum, or
Chronic abdominal pain unresponsive to medical therapy.
Diagnostic colonoscopy is
not covered for evaluation of the following:
Chronic, stable irritable bowel syndrome,
Acute limited diarrhea,
Hemorrhoids,
Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms, and when a definitive site of origin will not influence management,
Routine follow-up of inflammatory bowel disease (except as indicated above in this section),
Routine examination of the colon in patients about to undergo elective abdominal surgery for noncolonic disease,
Upper GI bleeding or melena with a demonstrated upper GI source,
Bright red rectal bleeding in patients with a convincing anorectal source via direct examination, anoscopy, or sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source,
Patients with a family history of colon cancer without a personal history of symptoms.
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