Monday, March 28, 2016

Colonoscopy Medical necessity guidelines - Part 1

Current Policy Statement

Health Net, Inc. considers colonoscopy medically necessary according to the guidelines set forth by the American Gastroenterological Association, the American Society of Colon & Rectal Surgeons, the American Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer, the American College of Radiology, the National Comprehensive Cancer Network, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy for patients who meet any of the following indications:

Diagnostic Colonoscopy

1. Evaluation of an abnormality on barium enema or other imaging study, which is likely to be clinically significant, such as a filling defect or stricture.
2. Evaluation of unexplained gastrointestinal bleeding, such as:
** Hematochezia not thought to be from rectum or perianal source, especially if the patient is > 40 years old.
** Melena of unknown origin after an upper GI source has been excluded.
** Presence of fecal occult blood.
3. Unexplained iron deficiency anemia.
4. Chronic inflammatory bowel disease of the colon if more precise diagnosis or determination of the extent of activity of disease will influence immediate management.
5. Clinically significant diarrhea of unexplained origin with additional symptoms (e.g., dehydration, weight loss).
6. Evaluation of acute colonic ischemia/ischemic bowel disease.
7. Evaluation of cytomegaloviral colitis in a patient with HIV infection
8. Evaluation of patient with Streptococcus bovis endocarditis.
9. 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).
10. Marking a neoplasm for surgical localization.
11. Constipation with involuntary weight loss of > 10 lbs within 12 weeks, or continued constipation following 2 weeks of treatment with fiber, hyperosmotic agents or stool softeners.

Therapeutic Colonoscopy
1. Excision of colonic polyp(s).
2. Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasia, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy).
3. Foreign body removal.
4. Decompression of pseudo-obstruction of the colon (Ogilvie's syndrome).
5. Decompression of acute nontoxic megacolon.
6. Treatment of sigmoid volvulus.
7. Balloon dilation of stenotic lesions (e.g., anastomotic strictures).
8. Palliative treatment of stenosing or bleeding neoplasms (e.g., laser, electrocoagulation, stenting).

Screening Colonoscopy

Initial screening colonoscopy for colorectal cancer at 50 years of age for asymptomatic, average risk men and women. If negative, rescreen with any accepted modality1 in 10 years.

Note: Screening may begin age 45 for African Americans because of the higher incidence of colorectal cancer.

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