LCD L34005: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

Abstract:

This LCD addresses the colonoscopies that are NOT performed for colorectal cancer screening. Colorectal cancer screening is a separate benefit with specific guidelines.

Proctosigmoidoscopy is the examination of the rectum and sigmoid colon.

Sigmoidoscopy is the examination of the entire rectum, sigmoid colon and may include examination of a portion of the descending colon.

Colonoscopy is the examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum. The colonoscope is inserted anally (or through a stoma) and is advanced optimally through the large intestine under direct vision, using the scope's optical system.

Indications:

The following are Medicare-covered indications:

• Evaluation of an abnormality discovered on barium enema and/or other imaging technique that is likely to be clinically significant, such as a filling defect or stricture or an inadequate examination;

• Evaluation of unexplained gastrointestinal bleeding:

• Hematochezia not thought to be from rectum or perianal source

• Melena of unknown origin;

• Presence of fecal occult blood

• Unexplained iron deficiency anemia;

• Surveillance of colonic neoplasia. When the patient has a history of colorectal cancer or polyps and is being followed for this indication;

• Examination to evaluate entire colon for synchronous cancer or polyps in a patient with treatable cancer or polyp;

• Follow-up in one year after surgery for treatment of colorectal cancer;

• This patient is identified as being at high-risk for colon cancer and is eligible for continued screening at 24-month intervals.

• Follow-up for removal of neoplastic polyp (follow-up at least three to six months to verify removal of large sessile adenoma [i.e., greater than 2 cm in greatest dimension] after colonoscopic removal);

• This patient is identified as being at high-risk for colon cancer and is eligible for continued screening at 24-month intervals.

• In patients with Crohn’s colitis and chronic ulcerative colitis: colonoscopy every one or two years with multiple biopsies for detection of cancer and dysplasia in patients with:

• Pancolitis of greater than seven years duration; or,

• Left-sided colitis of over 15 years duration (no surveillance needed for disease limited to rectosigmoid);

• Chronic inflammatory bowel disease of the colon if a more precise diagnosis or if a determination of the extent of activity of disease will influence immediate management;

• Clinically significant diarrhea of unexplained origin with additional findings (e.g., with weight loss or negative stool cultures persisting for more than 3 weeks;

• Intraoperative identification of the site of a lesion that can not be detected by palpation or gross inspection at surgery (e.g., polypectomy site or location of a bleeding source);

• Evaluation of acute colonic ischemia/ischemic bowel disease;

• Evaluation of patient 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 (Olgilvie’s syndrome);

• Treatment of sigmoid volvulus or stricture;

• Evaluation of unexplained, new onset constipation, refractory to medical therapy;

• Evaluation of anorectal polyp (adenomatous polyp only); or,

• Palliative treatment of stenosing, bleeding neoplasms (e.g., laser, electrocoagulation, stenting).

Limitations:

Endoscopy is generally not covered for treating the following, and records must have additional documentation indicating the medical necessity of the procedure for review as needed:

• Chronic, stable, irritable bowel syndrome, or chronic abdominal pain, There are unusual exceptions in which colonoscopy may be done to rule out organic disease, especially if symptoms are unresponsive to therapy;

• Acute diarrhea;

• Hemorrhoids;

• Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms when it will not influence management;

• Routine follow-up of inflammatory bowel disease (except for cancer surveillance in Crohn’s disease and chronic ulcerative colitis);

• Routine examination of the colon in patients about to undergo elective abdominal surgery for non-colonic disease;

• Upper gastrointestinal (GI) bleeding or melena with a demonstrated upper GI source; or,

• Bright red rectal bleeding with a convincing anorectal source on sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source;

Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy is generally not covered for:

• Fulminant colitis;

• Possible perforated viscus;

• Acute severe diverticulitis; or,

• Diverticulosis. This condition is not usually considered an indication for diagnostic or therapeutic colonoscopy, sigmoidoscopy or proctosigmoidoscopy, but may be reported on the claim when this condition is found to be the final diagnosis.

Other Comments:

For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC. to process their claims.

Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

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