UM Guidelines
Colonoscopy (Gastrointestinal Conditions)

Ambulatory Care (AC)
BCBST modification effective September 27, 2007*
Deleted Clinical Indications for the following diagnoses:
   
 

Milliman Care Guidelines Clinical Indications were deleted.
Added to: Clinical Indications
   

Colonoscopy is generally indicated in the following circumstances:1

  1. Evaluation of an abnormality on barium enema which is likely to be clinically significant, such as a filling defect or stricture
  2. Evaluation of unexplained gastrointestinal bleeding:
    1. Hematochezia in absence of convincing anorectal source
    2. Melena after an upper GI source has been excluded
    3. Presence of fecal occult blood
  3. Unexplained iron deficiency anemia
  4. Surveillance for colonic neoplasia:
    1. Examination to evaluate the entire colon for synchronous cancer of neoplastic polyps in a patient with treatable cancer or neoplastic polyp
    2. Clearing colonoscopy at or around the time of curative resection of cancer followed by colonoscopy at three years and three to five years thereafter to detect metachronous cancer
    3. Following adequate clearance of neoplastic polyp(s) survey at three- to five-year intervals
    4. Patients with significant family history:
      1. Hereditary nonpolyposis colorectal cancer: colonoscopy every two years beginning at the earlier of age 25, or five years younger than the earliest age of diagnosis of colorectal cancer. Annual screening colonoscopy should begin at age 40.
      2. Colorectal cancer or adenomatous polyps in a first-degree relative younger than 60 years, or in two or more first-degree relatives of any age, should receive an evaluation at age 40 or 10 years before the youngest case in the family, whichever is earlier. The interval for re-evaluation is 5 years.
    5. In patients with ulcerative pancolitis eight or more years' duration or left-sided colitis 15 or more years' duration every one to two years with systematic biopsies to detect dysplasia.
  5. Chronic inflammatory bowel disease of the colon if more precise diagnosis or determination of the extent of activity of disease will influence immediate management
  6. Clinically significant diarrhea of unexplained origin
  7. Intraoperative identification of a lesion not apparent at surgery (e.g., polypectomy side, location of a bleeding site)
  8. Treatment of bleeding from such lesions as vascular malformation, ulceration, neoplasia, and polypectomy site (e.g., electrocoagulation, heater probe, laser or injection therapy)
  9. Foreign body removal
  10. Excision of colonic polyp
  11. Decompression of acute nontoxic megacolon or sigmoid volvulus
  12. Balloon dilation of stenotic lesions (e.g., anastomotic strictures)
  13. Palliative treatment of stenosing or bleeding neoplasms (e.g., laser, electrocoagulation, stenting)
  14. Marking a neoplasm for localization

Colonoscopy is generally not indicated in the following circumstances:1

  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 diarrhea
  3. Metastatic adenocarcinoma of unknown primary site in the absence of colonic signs or symptoms when it will not influence management
  4. Routine followup of inflammatory bowel disease (except for cancer surveillance in chronic ulcerative colitis)
  5. Upper GI bleeding or melena with a demonstrated upper GI source

Colonoscopy is generally contraindicated:1

  1. When the risks to patient health or life are judged to outweigh the most favorable benefits of the procedure
  2. When adequate patient cooperation or consent cannot be obtained
  3. When a perforated viscus is known or suspected
  4. Fulminant colitis
  5. Documented acute diverticulitis

1Reprinted with the permission of the American Society for Gastrointestinal Endoscopy from Appropriate Use of Gastrointestinal Endoscopy, Revised November 1997.

* These guideline(s) have been revised from the Milliman USA Milliman Care Guidelines.  The portions of the guideline(s) which have been revised are identified through the use of [insert: italic, boldface, underlined, etc. as appropriate] text, and Milliman USA has neither reviewed nor approved the modified material.  Any statement to the contrary or association of the modified material with Milliman USA is strictly prohibited. This document has been classified as public information.
The above information only contains the modified portion of the Milliman Care Guideline. If you wish to view the complete Milliman Care Guideline, please contact Milliman USA.