Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A56394 (Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A56394: Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic (Billing and Coding, effective 2026-07-16)
- Covered ICD-10-CM codes
- 319
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 35
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| A04.3 | — |
| A04.5 | — |
| A04.71 | — |
| A04.72 | — |
| A06.1 | — |
| A06.2 | — |
| A06.9 | — |
| A09 | Infectious gastroenteritis and colitis, unspecified |
| A18.31 | — |
| A18.32 | — |
| A18.39 | — |
| A18.83 | — |
| B20 | Human immunodeficiency virus [HIV] disease |
| B95.1 | — |
| B95.2 | — |
| C18.0 | — |
| C18.1 | — |
| C18.2 | — |
| C18.3 | — |
| C18.4 | — |
| C18.5 | — |
| C18.6 | — |
| C18.7 | — |
| C18.8 | — |
Procedure codes: 44388, 44389, 44390, 44391, 44392, 44394, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45340, 45341, 45342, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45391, 45392.
Coverage indications, limitations and medical necessity
This LCD only applies to diagnostic colonoscopies and sigmoidoscopies. Refer to the Medicare Internet Only Manuals (IOM) for coverage of colorectal cancer screening procedures.
Sigmoidoscopy and colonoscopy testing allows for the direct visualization of the lower gastrointestinal tract. Inspection is performed with an illuminated tube. These procedures are performed to detect polyps, tumors and other lesions of the intestines. The site of pathology can be identified during a colonoscopy and a biopsy can be obtained.
Definitions:
• Sigmoidoscopy is the examination of the entire rectum and sigmoid colon, and includes 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.
Indications and Limitations of Coverage and/or Medical Necessity
A. The following are Medicare-covered indications for diagnostic colonoscopy:
• Evaluation of an abnormality on barium enema or other imaging study, which is likely to be clinically significant, such as filling a defect or stricture.
• Evaluation of unexplained gastrointestinal bleeding:
• Hematochezia not thought to be from rectum or perianal source,
• Melena of unknown origin; after an upper GI source has been excluded,
• Presence of fecal occult blood,
• Positive stool DNA test results. (e.g. guaiac/Fecal immunochemical test {FIT
Test}/Cologuard).
• Unexplained iron deficiency anemia.
• Examination to evaluate entire colon for synchronous cancer or polyps in a patient with treatable cancer or polyp.
• Chronic inflammatory bowel disease of the colon if more precise diagnosis or determination of the extent of activity of disease will influence immediate management.
• Clinically significant diarrhea of unexplained origin with additional symptoms (e.g., with weight loss).
• Intraoperative identification of the site of a lesion that cannot be detected by palpation or gross inspection at surgery (e.g., polypectomy site or location of a bleeding source).
• Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasm, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy).
• Removal of foreign body.
• Excision of colonic polyps.
• Decompression of acute nontoxic megacolon or sigmoid volvulus, pseudo-obstruction of the colon (Ogilvie’s syndrome).
• Balloon dilatation of stenotic lesions (e.g., anastomotic strictures).
• Palliative treatment of stenosing or bleeding neoplasm.
• Marking a neoplasm for localization.
• Evaluation of a patient with endocarditis due to streptococcus bovis or any bacterium of enteric origin.
• Suspected disease of terminal ileum.
• Evaluation of acute colonic ischemia/ischemic bowel disease.
• In patients with Crohn’s colitis and chronic ulcerative colitis: colonoscopy every 1 or 2 years with multiple biopsies for detection of cancer and dysplasia in patients with:
• Pancolitis of 8 or more years duration; or
• Left-sided colitis of 15 or more years duration.
• Evaluation within 6 months of the removal of sessile polyps to determine and document total excision. If evaluation indicates that residual polyp is present, excision should be done with repeat colonoscopy within 6 months. After evidence of total excision without return of the polyp, repeat colonoscopy yearly.
• Patients undergoing curative resection for colon or rectal cancer should undergo a colonoscopy 1 year after the resection (or 1 year following the colonoscopy that was performed to clear the colon of synchronous disease).
B. A diagnostic colonoscopy is not considered medically necessary for the following conditions:
• 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 limited 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 colitis, chronic ulcerative colitis).
• Routine examination of the colon in patients about to undergo elective abdominal surgery for non-colonic disease.
• Upper GI bleeding or melena with a demonstrated upper GI source.
C. A diagnostic flexible sigmoidoscopy is covered for the following indications:
• Evaluation of suspected distal colonic disease when there is no indication for a colonoscopy.
• Evaluation for anastomotic recurrence in rectosigmoid carcinoma.
• All of the covered indications listed for a diagnostic colonoscopy.
D. A diagnostic flexible sigmoidoscopy is not indicated when a colonoscopy is indicated.
Summary of evidence (opening)
NA
The contractor cites 10 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2026-08-27
- Last reviewed by the contractor
- 2026-07-02
- MCD version
- 45
- Derived from
- L30304
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Wisconsin Physicians Service Insurance Corporation hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L34614 cover?
This LCD only applies to diagnostic colonoscopies and sigmoidoscopies. Refer to the Medicare Internet Only Manuals (IOM) for coverage of colorectal cancer screening procedures. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L34614 apply to?
Wisconsin Physicians Service Insurance Corporation applies it to Medicare claims in AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L34614?
The companion billing and coding article A56394 lists 319 ICD-10-CM codes in 1 group that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L34614?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.