Tuesday, April 5, 2016

Colonsocopy Not Medically Necessary: condition

Health Net, Inc. considers colonoscopy not medically necessary for any of the following circumstances:

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

2. Acute limited diarrhea.

3. Hemorrhoids.

4. Bright red rectal bleeding in patients with a convincing anorectal source on sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source

5. Metastatic adenocarcinoma of unknown primary site in the absence of colonic signs or symptoms when it will not influence management.

6. Routine follow-up of inflammatory bowel disease (except for cancer surveillance in chronic ulcerative colitis and Crohn's colitis).

7. Upper GI bleeding or melena with a demonstrated upper GI source.

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

Relative contraindications to colonoscopy:

1. Toxic megacolon and fulminant colitis.

2. Peritonitis

3. Known or suspected colonic necrosis.

4. Documented acute severe diverticulitis / diverticular abscess.

5. Possible perforated viscus.

6. Severe coagulopathy, severe thrombocytopenia, severe neutropenia

7. History of radiation therapy for abdominal or pelvic cancer

8. History of abdominal or pelvic malignancy

9. Extensive adhesions from prior abdominal surgery

10. Pregnancy *

Note* - Colonoscopy is currently contraindicated during pregnancy because of inadequate data on safety but may be strongly considered for severe life-threatening colonic conditions such as suspected colon cancer, evaluation of a right-sided colonic mass, and uncontrolled severe right-colonic hemorrhage, and to guide segmental colectomy for urgent colonic surgery.

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