2013 NATIONAL COVERAGE DETERMINATION (NCD) CPT CODE(S): 82272, G0328 FECAL OCCULT BLOOD

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1 ABDOMINAL OR PELVIC SWELLING, MASS, OR LUMP ABDOMINAL PAIN ABDOMINAL RIGIDITY ABDOMINAL TENDERNESS ABNORMAL COAGULATION PROFILE ABNORMAL FECES ABNORMAL LOSS OF WEIGHT ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, IN RELAPSE ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACUTE LYMPHOID LEUKEMIA, IN RELAPSE ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE ACUTE MYELOID LEUKEMIA, IN RELAPSE ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION AND IN REMISSION AMEBIASIS 569 ANAL AND RECTAL POLYP ANAL FISSURE AND FISTULA ANGIODYSPLASIA OF INTESTINE WITH OR WITHOUT MENTION OF HEMORRHAGE ANGIODYSPLASIA OF STOMACH AND DUODENUM ANOREXIA ANTINEOPLASTIC CHEMOTHERAPY INDUCED ANEMIA BENIGN CARCINOID TUMORS OF THE APPENDIX, LARGE INTESTINE AND RECTUM BENIGN CARCINOID TUMORS OF THE SMALL INTESTINE Page 1 of 8

2 BENIGN NEOPLASM OF OTHER PARTS OF DIGESTIVE SYSTEM BILIOUS EMESIS CARCINOMA IN SITU OF DIGESTIVE ORGANS CELIAC DISEASE CHRONIC ERYTHREMIA, IN RELAPSE CHRONIC ERYTHREMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION AND IN REMISSION CHRONIC FATIGUE SYNDROME CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE CHRONIC LIVER DISEASE AND CIRRHOSIS CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING CHRONIC MONOCYTIC LEUKEMIA, IN RELAPSE CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING CHRONIC MYELOID LEUKEMIA, IN RELAPSE CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING COAGULATION DEFECTS COLIC CRUSHING INJURY OF TRUNK, MULTIPLE SITES CRUSHING INJURY OF TRUNK, OTHER SPECIFIED SITES CRUSHING INJURY OF TRUNK, UNSPECIFIED SITE DIARRHEA DIEULAFOY LESION (HEMORRHAGIC) OF INTESTINE DIEULAFOY LESION (HEMORRHAGIC) OF STOMACH AND DUODENUM , , , DISEASES OF THE ESOPHAGUS Page 2 of 8

3 DISEASES OF THE PANCREAS DISSEMINATED MALIGNANT NEOPLASM DIVERTICULOSIS/DIVERTICULITIS OF COLON DYSPEPSIA AND OTHER SPECIFIED AND UNSPECIFIED FUNCTIONAL DISORDERS OF STOMACH DYSPHAGIA, ORAL PHASE DYSPHAGIA, OROPHARYNGEAL PHASE DYSPHAGIA, PHARYNGEAL PHASE DYSPHAGIA, PHARYNGO-ESOPHAGEAL PHASE DYSPHAGIA, UNSPECIFIED ENDOMETRIOSIS OF INTESTINE EOSINOPHILIC COLITIS EOSINOPHILIC GASTRITIS, WITH OBSTRUCTION EOSINOPHILIC GASTRITIS, WITHOUT MENTION OF OBSTRUCTION EOSINOPHILIC GASTROENTERITIS ESOPHAGEAL VARICES WITH OR WITHOUT MENTION OF BLEEDING FAILED MODERATE SEDATION DURING PROCEDURE V67.51 FOLLOWING TREATMENT W/ HIGH RISK MEDICATION, NOT ELSEWHERE SPECIFIED FUNCTIONAL DIGESTIVE DISORDERS, NOT ELSEWHERE CLASSIFIED FUNCTIONAL QUADRIPLEGIA GASTRIC ULCER; DUODENAL ULCER; PEPTIC ULCER, SITE UNSPECIFIED; GASTROJEJUNAL ULCER; AND GASTRITIS AND DUODENITIS GASTROINTESTINAL HEMORRHAGE GONOCOCCAL ENDOCARITIS GONOCOCCAL INFECTION ANUS AND RECTUM GONOCOCCAL INFECTION, ACUTE, LOWER GENITOURINARY TRACT HEARTBURN HEMANGIOMA OF INTRA-ABDOMINAL STRUCTURES HEMORRHAGE OF RECTUM AND ANUS HEMORRHOIDS Page 3 of 8

4 448.0 HEREDITARY HEMORRHAGIC TELANGIECTASIA ILL-DEFINED INTESTINAL INFECTIONS INJURY TO BLOOD VESSELS OF ABDOMEN AND PELVIS INJURY TO GASTROINTESTINAL TRACT , INJURY TO GASTROINTESTINAL TRACT INJURY TO KIDNEY WITH OPEN WOUND INTO CAVITY INJURY TO KIDNEY WITHOUT MENTION OF OPEN WOUND INTO CAVITY INJURY TO LIVER WITH OPEN WOUND INTO CAVITY INJURY TO LIVER WITHOUT MENTION OF OPEN WOUND INTO CAVITY INTESTINAL INFECTIONS DUE TO OTHER SPECIFIED BACTERIA INTESTINAL OBSTRUCTION/IMPACTION WITHOUT MENTION OF HERNIA INTESTINOVESICAL FISTULA IRON DEFICIENCY ANEMIAS KAPOSI S SARCOMA, GASTROINTESTINAL SITES LATE EFFECTS OF OTHER AND UNSPECIFIED INFECTIOUS AND PARASITIC DISEASES V58.61 LONG TERM (CURRENT) USE OF ANTICOAGULANTS V58.69 LONG TERM (CURRENT) USE OF OTHER MEDICATIONS V58.63-V58.65 LONG-TERM (CURRENT) DRUG USE V58.66 LONG-TERM (CURRENT) USE OF ASPIRIN MALIGNANT ASCITES MALIGNANT CARCINOID TUMORS OF THE APPENDIX, LARGE INTESTINE & RECTUM MALIGNANT CARCINOID TUMORS OF THE SMALL INTESTINE MALIGNANT NEOPLASM OF DIGESTIVE ORGANISMS MALIGNANT NEOPLASM OF OTHER AND ILL-DEFINED SITES WITHIN THE DIGESTIVE ORGANS AND PERITONEUM MEGAKARYOCYTIC LEUKEMIA, IN RELAPSE MEGAKARYOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING Page 4 of 8

5 MYELOID SARCOMA, IN RELAPSE MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION AND IN REMISSION MYELOPHTHISIS NAUSEA AND VOMITING NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER & UNSPECIFIED DIGESTIVE ORGANS NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH, INTESTINES, AND RECTUM NEOPLASM OF UNSPECIFIED NATURE, DIGESTIVE SYSTEM NEOPLASM RELATED PAIN (ACUTE) (CHRONIC) NON-INFECTIOUS ENTERITIS AND COLITIS NON-INFECTIOUS ENTERITIS AND COLITIS NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION, ABDOMINAL AREA, INCLUDING RETROPERITONEUM NONSPECIFIC ABNORMAL FINDINGS IN STOOL CONTENTS NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDIES, LIVER OTHER AND UNSPECIFIED ANEMIAS OTHER ASCITES OTHER CESTODE INFECTION OTHER DISORDERS OF STOMACH AND DUODENUM OTHER DYSPHAGIA , , , OTHER FOOD POISONING (BACTERIAL) OTHER INTESTINAL HELMINTHIASES OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING OTHER LYMPHOID LEUKEMIA, IN RELAPSE OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING Page 5 of 8

6 OTHER MALAISE AND FATIGUE OTHER MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING OTHER MONOCYTIC LEUKEMIA, IN RELAPSE OTHER MYELOID LEUKEMIA, IN RELAPSE OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING OTHER PROTOZOAL INTESTINAL DISEASES , OTHER SPECIFIED DISORDERS OF RECTUM AND ANUS OTHER SPECIFIED DISORDERS OF STOMACH AND DUODENUM OTHER SPECIFIED INTESTINAL MALABSORPTION OTHER SPECIFIED LEUKEMIA, IN RELAPSE OTHER SPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING OTHER SYMPTOMS INVOLVING DIGESTIVE SYSTEM PERSISTENT VOMITING V12.72 PERSONAL HISTORY OF COLONIC POLYPS V10.00-V10.09 PERSONAL HISTORY OF MALIGNANT NEOPLASM, GASTROINTESTINAL TRACT V12.00 PERSONAL HISTORY OF UNSPECIFIED INFECTIOUS AND PARASITIC DISEASE POISONING BY AGENTS PRIMARILY AFFECTING BLOOD CONSTITUENTS, ANTICOAGULANTS PURPURA AND OTHER HEMORRHAGIC CONDITIONS RECTAL PROLAPSE SALMONELLA GASTROENTERITIS SALMONELLA SEPTICEMIA SECONDARY MALIGNANT NEOPLASM OF INTESTINES SECONDARY MALIGNANT NEOPLASM OF OTHER DIGESTIVE ORGANS & SPLEEN SECONDARY MERKEL CELL CARCINOMA SECONDARY NEUROENDOCRINE TUMOR OF BONE Page 6 of 8

7 SECONDARY NEUROENDOCRINE TUMOR OF DISTANT LYMPH NODES SECONDARY NEUROENDOCRINE TUMOR OF LIVER SECONDARY NEUROENDOCRINE TUMOR OF OTHER SITES SECONDARY NEUROENDOCRINE TUMOR OF PERITONEUM SECONDARY NEUROENDOCRINE TUMOR, UNSPECIFIED SITE SHIGELLOSIS SIDERBLASTIC ANEMIA AND ANEMIA OF OTHER CHRONIC DISEASE SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING SUBACUTE MONOCYTIC LEUKEMIA, IN RELAPSE SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING SUBACUTE MYELOID LEUKEMIA, IN RELAPSE SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING SYPHILIS OF LIVER SYPHILITIC PERITONITIS 124 TRICHINOSIS TUBERCULOSIS OF INTESTINES, PERITONEUM, AND MESENTERIC GLANDS ULCERATION AND PERFORATION OF INTESTINE UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE UNSPECIFIED LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE UNSPECIFIED LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE Page 7 of 8

8 UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING UNSPECIFIED MONOCYTIC LEUKEMIA, IN RELAPSE UNSPECIFIED MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING VOMITING OF FECAL MATTER WHIPPLE S DISEASE Page 8 of 8