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Flexible sigmoidoscopy is a visual examination of the rectum and lower colon called the sigmoid colon. A sigmoidoscope, long flexible tube with fiber optics, is passed through the anus and rectum into the sigmoid colon. Instruments and tools can be passed through the scope, for taking samples (biopsies). This procedure may be performed in the outpatient setting.

Virtual colonoscopy, also known as computed tomography (CT) colonography,  is an imaging technique of the colon involving thin-section helical CT to generate high-resolution 2-dimensional axial images of the colon. Three-dimensional images, which resemble the endoluminal images obtained with conventional endoscopic colonoscopy, are then reconstructed off line. Virtual colonoscopy has been investigated as an alternative to conventional endoscopic colonoscopy, specifically as an alternative screening technique for colon cancer. While virtual colonoscopy  requires a full bowel preparation, similar to conventional colonoscopy, no sedation is required, and the examination is less time consuming. However, gas insufflation of the intestine, which may be uncomfortable to the patient, and interpretation of the images is described as difficult and time consuming.

Screening (asymptomatic individuals) colonoscopy, fecal occult blood test (FOBT) and sigmoidoscopy will be allowed under the following guidelines:

Beginning at age 50, both men and women should follow ONE of the screening options below:

1. Yearly FOBT plus flexible sigmoidoscopy every 5 years, OR

2. Yearly FOBT plus colonoscopy every 10 years

A digital rectal examination (DRE) should be performed at the time of EACH screening sigmoidoscopy or colonoscopy.

People should begin colorectal cancer screening earlier and/or undergo screening more often if they have any of the following colorectal cancer risk factors. Frequency should be determined by the ordering physician:

• Familial syndromes that have a high incidence of developing neoplasia (such as familial adenomatous polyposis and hereditary non-polyposis colon cancer), as well as any patient age >35 with 2 first degree relatives (parents, siblings, and children) with colon cancer at any age OR 1 first degree relative with colon cancer at age <60. Note: A first degree relative is defined as a parent, sibling, or child.
• A personal history of colorectal cancer or adenomatous polyps, or
• A personal history of chronic inflammatory bowel disease or irritable bowel syndrome.

Inflammatory Bowel Disease

Most patients do not require colonoscopy for initial diagnosis, unless clinical sigmoidoscopy and radiological studies fail to secure diagnosis. Multiple biopsies are helpful when it is clinically necessary to distinguish between ulcerative colitis and Crohn's. Screening colonoscopy for follow-up of inflammatory bowel disease is usually not covered except for cancer surveillance in chronic ulcerative colitis.

Abnormal Exam (Symptomatic individuals)

Colonoscopy is considered medically necessary under the following circumstances:

1. Hematochezia (bright red bloody stool) NOT thought to be from a rectal or perianal source. Please note the following:

   • Scant hematochezia: Chronic intermittent visible bright red blood most often represents an anal lesion. Spots or drops post defecation suggest an anal lesion, while streaks of blood on formed stools suggests rectal or digital colonic origin. Diagnostic evaluation should have included inspection of the anus, digital exam, anoscopy, and sigmoidoscopy.
   • Colonoscopy is not medically necessary for bright red rectal bleeding in patients with anorectal source on sigmoidoscopy, and no other symptoms suggestive of a source higher in the colon.)
   • Melena of unknown origin
   • Presence of fecal occult blood (heme, guaiac+) in age >40

1. That is clinically significant and of unexplained origin.

1. Evaluation of an abnormality on barium enema that is likely to be clinically significant, such as a stricture or a filling defect
2. Evaluation of acute colonic ischemia or ischemic bowel disease
3. Intraoperative identification of the site of a lesion that cannot be detected by palpation or gross inspection at surgery (such as polypectomy site or location of a bleeding source)
4. Treatment of colonic volvulus or pseudo-obstruction
5. Evaluation of patient with strep bovis endocarditis
6. Unexplained iron deficiency anemia
7. Removal of a foreign body

1. Upper GI bleeding or melena with a known upper GI source. For intermittent melena, since an upper tract source is most likely, patients should begin with upper endoscopy.
2. Bright red rectal bleeding in patients with anorectal source on sigmoidoscopy, and no other symptoms suggestive of a source higher in the colon. Please note the following:

Scant hematochezia: Chronic intermittent visible bright red blood most often represents an anal lesion. Spots or drops post defecation suggest an anal lesion, while streaks of blood on formed stools suggests rectal or digital colonic origin. Diagnostic evaluation should have included inspection of the anus, digital exam, anoscopy, and sigmoidoscopy.

1. Metastatic adenocarcinoma of unknown primary, in the absence of colonic symptoms, when colonoscopy results will not influence management.
2. Diarrhea that is acute, limited.
3. Other routine examination of the colon in patients about to undergo elective abdominal surgery for colonic disease.

• Severe active colitis or toxic megacolon
• Peritonitis
• Possible perforated viscus
• Acute severe diverticulitis

Flexible sigmoidoscopy in the ambulatory or office-setting is considered medically necessary under the following circumstances:

1. Follow-up for recurrent neoplasia
2. Surveillance for neoplasia in patient with subtotal colectomy for cancer or ileoproctostomy for familial polyposis
3. Evaluation of lower GI symptoms in conjunction with barium enema x-rays
4. Evaluation of a rectosigmoid stricture demonstrated on barium x-ray
5. Acute colitis
6. Anorectal symptoms: bleeding, pain, itching
7. Familial syndromes with high incidence of developing neoplasia

Computed tomography (CT) colonography, commonly referred to as virtual colonoscopy, may be considered medically necessary in patients for whom a conventional colonoscopy is indicated but who are unable to undergo conventional colonoscopy for medical reasons or in patients with an incomplete conventional colonoscopy because of colonic stenosis or obstruction.

Except as noted in the policy statement above, CT colonography is considered not medically necessary for the purposes of colon cancer screening because the clinical outcomes with this screening strategy have not been shown to be superior to other approaches including optical colonoscopy.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Computed tomography (CT) colonography should be performed with a minimum 16-row detector CT scanner. 

Contraindications to conventional colonoscopy may include continuous anticoagulation therapy or high anesthesia risk. 

3/1999: Updated to reflect national standards

2/2001: Reviewed by MPAC; Virtual colonoscopy considered investigational. Healthy you guidelines will be aligned to be consistent with the American Cancer Society recommendations for early colorectal cancer detection.

5/23/2001: Code reference section revised; ICD-9 diagnosis code 235.2 and 239.0 deleted

11/14/2001: Colonoscopy and flexible sigmoidoscopy description revised under the "Description" section.

2/13/2002: Investigational definition added

3/20/2002: Revised verbiage of familial syndromes for clarity

3/26/2002: Healthy You guideline for barium enema deleted; G0121 added to non-covered

3/27/2002: Healthy You guidelines moved to Policy Exceptions

4/18/2002: Type of Service and Place of Service deleted

6/12/2002: ICD-9 diagnosis codes 235.2 and 239.0 added

7/23/2002: Policy section revised, Policy Exceptions deleted

7/30/2002: Prior authorization deleted

8/22/2002: CPT codes 44390-44397, 45332-45345, 45382-45387 deleted; ICD-9 procedure codes 45.42-45.43 deleted; ICD-9 diagnosis codes 555.9, 787.99, 799.8 deleted; ICD-9 diagnosis codes 557.1- 557.9 added; ICD-9 diagnosis code 564.89 description revised and one deleted; ICD-9 diagnosis code 556.9 is covered and non-covered depending on the description

12/11/2002: HCPCS G0102 added

11/18/2004: Reviewed by MPAC, CT colonography (“virtual colonoscopy”) remains investigational, policy title “Colonoscopy and Flexible Sigmoidoscopy” renamed “Colonoscopy, Flexible Sigmoidoscopy, and CT Colonography,” Description section updated to be consistent with BCBSA policy # 6.01.32, Sources updated

4/12/2005: Code Reference section updated, CPT code 44390, 44392, 44393, 44394, 45307, 45332, 45333, 45338, 45339, 45383, 45384, 45385 added covered codes, ICD-9 procedure code 45.42, 45.43, 98.03, 98.04 added covered codes, ICD-9 diagnosis 560.89 added covered codes, ICD-9 diagnosis codes 578.1 description revised covered codes, HCPCS G0102 deleted covered codes, HCPCS G0328 added covered codes, HCPCS 0066T, 0067T added non-covered codes, ICD-9 diagnosis code 556.9, 562.11, 562.13, 567.9, 569.49, 569.83, V72.83 deleted non-covered codes

3/13/2006: Coding updated. CPT4 2006 revisions added to policy

3/21/2006: Policy reviewed, no changes

09/13/2006: Coding updated.  ICD9 2006 revisions added to policy

12/27/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions

12/17/2007: Coding updated. CPT/HCPCS 2008 revisions added to policy

7/8/2008: Anesthesia Coding Policy hyperlink added

9/15/2008: Code reference section updated per the annual ICD-9 updates effective 10-1-2008

9/29/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. HCPC code G0107  deleted from covered table due to code was deleted as of 12-31-06.

04/12/2010: Policy Statement revised to include CT Colonography may be considered medically necessary in patients with medical reasons. Code Reference Section updated revised to identify deleted codes S0605, 0066T and 0067T.  Added new CPT Code 74261 and 74262 to the Covered Codes Table and CPT Code 74263 to Non-Covered Codes Table.

07/12/2012: Policy reviewed; no changes to policy statement.  Removed S0605, 0066T, and 0067T from the Code Reference section as these codes have been deleted.

05/08/2013: Policy reviewed; no changes.

American Society of Gastroendoscopy (ASGE) consensus statement, "The Appropriate Use of Gastrointestinal Endoscopy"

Guidelines for Clinical Applications by the ASGE; Publication Nos. 1009 and 1013 1986.

United States Preventive Services Task Force (USPSTF) 1996 recommendation

American Cancer Society, Colon and Rectum Cancer Resource Center recommendations for early colorectal cancer detection

TEC Assessment Program, Volume 19, No. 6, July 2004 

Blue Cross Blue Shield association policy #6.01.32

For Coding Guidelines see the Anesthesia Coding Policy .

Covered Codes

This is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Non-Covered Codes

This is not an all-inclusive list of non-covered procedure codes.

The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure.

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