Colonoscopy describes the direct visual inspection of the entire colon and rectum.  Additionally, biopsy or excision of polyps or other abnormalities are possible during the colonoscopy procedure. 

Colonoscopy must be distinguished from CT colonography, an imaging procedure that provides indirect visualization of the colon and rectum using CT scans.  This procedure is considered separately in RAD.00029.

NOTE: The parenthetical numbers in the Clinical Indications section refer to the source documents cited in the References Section below. 

Screening Colonoscopy 

Medically Necessary: 

Screening Colonoscopy in Average Risk (i.e., those without specific risk factors or family history of colorectal cancer or adenomas and asymptomatic populations).

• Colonoscopy to detect colorectal cancer and adenomatous polyps is appropriate:
  • beginning at age 50 years (7, 8, 9, 11) or age 45 years for African Americans (1), and 
  • every 10 years thereafter.  (2, 7, 8, 11)

Note: The higher incidence and younger age at presentation of colorectal cancer in African Americans warrant initiation of colorectal cancer screening at age 45 years rather than 50 years. (1)        

Screening Colonoscopy in Higher Risk (or Increased Risk) Populations

• Colorectal Cancer: For those with a personal history of colorectal cancer that has been resected with curative intent, colonoscopy is appropriate for any of the following:
  • To rule out synchronous neoplasms; 3 to 6 months after cancer resection, if no unresectable metastases are found during surgery; Alternatively, colonoscopy can be performed intraoperatively, or preoperatively if non-obstructing tumor; (7) or
  • 1 year after the curative resection if a complete preoperative colonoscopy was performed, or 3-6 months after curative resection if there was no or incomplete preoperative colonoscopy, or 1 year following the colonoscopy that was performed to clear the colon of synchronous disease; (7, 11) or
  • 2 to 3 years after the "1 year" follow up colonoscopy, if examination was normal.; (2, 7, 11) or
  • thereafter at 3 to 5 year intervals, based on previous findings. (2, 7, 11)
• Adenomatous Polyps: Those who have a prior personal history of having one or more adenomatous polyps removed at colonoscopy should be managed according to the findings (i.e., considering number of polyps and pathology).  Colonoscopy may be appropriate in any of the following individuals:
  • those with 1 or 2 small (less than 1 cm) tubular adenomas should have the first follow up colonoscopy in 5 years; (2, 11) or
  • those with 3 to 10 adenomas or 1 adenoma greater than 1 cm or any adenoma with villous features or high-grade dysplasia should have colonoscopy 3 years after the initial polypectomy; (7, 11).  Those with greater than 10 adenomas on a single examination should have colonoscopy less than 3 years after the initial polypectomy based on clinical judgment; (7) or
  • those with a malignant adenoma (with invasive cancer), a large sessile adenoma, or an incomplete colonoscopy should have a short interval follow up based on clinical judgment; (2) or
  • those with sessile adenomas that are removed piecemeal should have their first follow-up colonoscopy at 2 to 6 months to verify complete removal; (7).
    
    The timing of the subsequent colonoscopy should depend on the pathology and the number of adenomas detected at the "follow-up colonoscopy." For example, if the first "follow-up colonoscopy" is normal or only 1 or 2 small (less than 1cm) tubular adenomas are found, then the next colonoscopy can be in 5 years. (2)

• Family History of Colorectal Cancer or Adenomas: The vast majority of those with increased risk are in this category. Screening colonoscopy would be appropriate for a person with a family history indicating any of the following:
  • one first degree relative (parent, sibling or child) with colon cancer or adenoma diagnosed before the age    of 60; or (2, 3, 4, 7)
  • two or more first-degree relatives with colorectal cancer or adenomas at any age: (2, 7)
    • colonoscopy beginning at age 40;  (2, 7, 8, 11) or
    • colonoscopy beginning at an age 10 years younger than the age at diagnosis of the youngest affected relative, which ever comes first. (2, 7, 8, 11)
    • for this specific group, colonoscopy may be repeated every 3 to 5 years depending on findings. (4, 8, 11)
  • For those with one or more first degree relatives with colorectal cancer or adenoma diagnosed at an age greater than or equal to 60 years or two second degree relatives (grandparents, aunts or uncles), screening is the same as "average" risk (colonoscopy every 10 years) but it should begin at age 40. (2, 3, 4, 7, 11)
• Familial adenomatous polyposis (FAP): In this autosomal dominant syndrome, affected persons have a risk of colorectal cancer approaching 100%. The average age of adenoma appearance is 16, and the average age of colon cancer is 39. Most affected individuals develop more than 100 adenomas. Thus early and regular screening is appropriate for any of the following. (2)
  • For those with a genetic diagnosis of FAP, or who are at risk for this diagnosis but genetic testing has not been done or is not feasible:
    • offer genetic counseling, as specific genetic abnormalities can be identified in approximately 80% of affected individuals. This can then be used to screen other family members. (2, 4, 8) and
    • annual sigmoidoscopy beginning at ages 10-12 years: (2, 4, 7, 8)
      1. with an appropriately timed colectomy indicated when polyps develop; (4, 5) or
      2. if no polyps develop, annual sigmoidoscopy to age 40 then every 3-5 years thereafter. (4)
  • For the family members of those with FAP who do not have specific genetic evidence or clinical manifestations of the disease:
    • the older, unscreened relatives of a person newly diagnosed with FAP should have a colonoscopy for the first screening examination; (8) and
    • annual screening sigmoidoscopy until age 40 if no polyps develop; (8) and
    • an appropriately timed colectomy indicated if polyps develop. (5, 8)

Note: While the above is applicable to individuals with FAP and their families, there are variants of this syndrome, attenuated adenomatous polyposis coli (AAPC) (also referred to as attenuated FAP) and MYH-associated polyposis. The genetic mutations leading to these variants differ from that in the typical FAP individual. These variants are associated with a variable number of adenomas (usually 20 to 100), a tendency toward right sided lesions, and an age of onset of colorectal cancer that is approximately 10 years later than for others with FAP. As with FAP, genetic counseling for these individuals and early and regular screening is warranted. It is recommended that this screening begin in the late teens or early 20s, depending on the age of polyp expression in the family. (11)

• Lynch Syndrome, also known as Hereditary Non Polyposis Colorectal Cancer (HNPCC): For individuals with a genetic or clinical diagnosis of, or who are at increased risk for Lynch Syndrome, colonoscopy is appropriate as follows:
  • Every 1 to 2 years beginning at 20 to 25 years old until age 40 (when annual screening should begin); (2, 7, 8, 11) or
  • Every 1-2 years beginning at an age which is 10 years younger than the youngest age of diagnosis of colorectal cancer in the family, then annual screening after age 40, which ever is earlier; (2, 7, 11) and
  • Annually after age 40. (3, 4, 5, 8, 11)
• Inflammatory Bowel Disease and related conditions (which includes either chronic ulcerative colitis or Crohn's colitis):  For individuals with inflammatory bowel disease, colonoscopy is appropriate as follows:
  • All individuals, regardless of the extent of disease at initial diagnosis, should undergo a screening colonoscopy a maximum of 8 years after onset of symptoms, with multiple biopsy specimens obtained throughout the entire colon to assess the true microscopic extent of inflammation; (12) or
  • Individuals with extensive or left-sided colitis should begin surveillance within 1 to 2 years after the initial screening endoscopy. Surveillance examinations should be performed every 1 to 3 years; (12) and
  • Individuals with primary sclerosing cholangitis (PSC) should begin surveillance colonoscopy at the time of diagnosis and then undergo yearly colonoscopy thereafter; (12).
  • These recommendations also apply to individuals with Crohn's colitis who have disease involving at least one third of the length of the colon. (12)

Not Medically Necessary:

Other indications for screening colonoscopy, not listed above, are considered not medically necessary.

Diagnostic Colonoscopy 

Medically Necessary:

Diagnostic Colonoscopy is indicated for the evaluation of any of the following:

• an abnormality on barium enema or other imaging study that is likely to be clinically significant (filling defect, stricture); (3) or
• unexplained gastrointestinal tract bleeding such as:  (3) 
  • hematochezia (3) or
  • melena after an UGI tract source has been excluded; (3) or
  • presence of fecal occult blood (3)  or
  • unexplained iron deficiency anemia; (3)  or
• a suspicion of inflammatory bowel disease, which may be manifested by abdominal pain, fever, diarrhea, bloody diarrhea, elevated erythrocyte sedimentation rate, etc.; or
• clinically significant diarrhea of unexplained origin (3) after other appropriate work up; or
• a metastatic adenocarcinoma of unknown primary origin when colon cancer is suspected; (10) or
• intraoperative identification of a lesion not apparent at surgery (e.g., polypectomy site, location of a bleeding site). (3)  

Not Medically Necessary: 

Other indications for diagnostic colonoscopy, not listed above are considered not medically necessary, including but not limited to the following:

• chronic, stable irritable bowel syndrome; (3, 9) and
• chronic abdominal pain; (3, 9) and
• acute diarrhea; (3, 9) and
• routine follow-up of inflammatory bowel disease except for cancer surveillance in chronic ulcerative colitis and Crohn's colitis; (3, 9) and
• upper GI tract bleeding or melena with a demonstrated upper GI source.  (3, 9)

Therapeutic Colonoscopy: 

Medically Necessary: 

Therapeutic Colonoscopy is generally indicated for any of the following:

• removal of foreign body; (3) or
• balloon dilation of stenotic lesions (e.g., anastomotic strictures); (3) or
• excision of colonic polyps; (3) or
• decompression of sigmoid volvulus or an acute nontoxic megacolon; (3) or
• palliative treatment of stenosing or bleeding neoplasms (e.g., laser, electrocoagulation, stenting); (3) or
• treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasia, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy); (3) or
• pre-operative "marking" for localization of a lesion. (3)

Not Medically Necessary:

Other indications for therapeutic colonoscopy, not listed above are considered not medically necessary. 

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Screening, surveillance and diagnostic indications for colonoscopy are based on guidelines from a variety of specialty societies and government organizations.  The source for each of the indications listed above is indicated by the referenced citation.

1. Agrawal S, Bhupinderjit A, Bhutani MS, et al. Colorectal cancer in African Americans. Am J Gastroenterol. 2005; 10(3)0:515-523. 
2. American Gastroenterological Association. Colorectal Cancer Screening and Surveillance: Clinical Guidelines and Rationale.  Update Based on New Evidence. Gastroenterology, February 2003.Vol 124.  Available at: http://download.journals.elsevierhealth.com/pdfs/journals/0016-5085/PIIS0016508502158951.pdf.  Accessed on March 22, 2010.
3. American Society for Gastrointestinal Endoscopy (ASGE). Appropriate use of gastrointestinal endoscopy. 2003. Available at: http://www.asge.org/WorkArea/showcontent.aspx?id=3394. Accessed on March 22, 2010.
4. American Society for Gastrointestinal Endoscopy. Colonoscopy in the screening and surveillance of individuals at increased risk for colorectal cancer. Gastrointest Endosc. 2006; 63(4):546-557.
5. Centers for Medicare and Medicaid Services. National Coverage Determination for Colorectal Cancer Screening Tests. NCD #210.3. Effective January 1, 2004. Available at: http://www.cms.hhs.gov. Accessed on March 22, 2010.
6. Farraye FA, Odze RD, Eaden J, et al. American Gastroenterological Association (AGA). AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease.  Gastroenterology. 2010; 138(2):738-745.  Available at:  http://download.journals.elsevierhealth.com/pdfs/journals/0016-5085/PIIS0016508509022021.pdf. Accessed on March 22, 2010.
7. Giardiello FM, Brensinger D, Petersen GM.  American Gastroenterological Association (AGA) technical review on hereditary colorectal cancer and genetic testing. Gastroenterology 2001; 121(1):198-213. Available at: http://usagiedu.com/articles/gencan/gencan.pdf.  Accessed on March 22, 2010.
8. Levin B, Lieberman DA, McFarland B, et al. Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin. 2008; 58(3):130-160.  Available at:  http://caonline.amcancersoc.org/cgi/content/full/CA.2007.0018v1  Accessed on March 22, 2010.
9. National Comprehensive Cancer Network.  Colorectal Cancer Screening V1.2010.  Available at: http://www.nccn.org/professionals/physician_gls/PDF/colon.pdf   Accessed on March 22, 2010.
10. Rex DK, Johnson DA, Anderson JC, et al.  American College of Gastroenterology guidelines for colorectal cancer screening 2008.  Available at: http://www.gi.org/media/releases/ACG2009CRCGuideline.pdf  Accessed on March 22, 2010.
11. US Preventive Services Task Force.  Screening for colorectal cancer.  US Preventive Service Task Force recommendation statement.  Ann Intern Med 2008; 149(9):627-637.  Available at:  http://www.guideline.gov/summary/summary.aspx?doc_id=13133&nbr=006722&string=colorectal+AND+cancer+AND+screening  Accessed on March 22, 2010.
12. Worthington DV.  American Academy of Family Physicians (AAFP) position paper:  Colonoscopy: procedural skills. Am Fam Physician. 2000; 62(5):1177-1182. Available at: http://www.aafp.org/afp/20000901/aafp.html.  Accessed on March 22, 2010.

Colonoscopy
Cancer Screening