Does Medicare Cover Colonoscopy?: Rules for Reimbursement
- When it comes to health screenings, beneficiaries may wonder: Does Medicare cover a colonoscopy? Learn the simple rules for Medicare reimbursement of this exam.
Because colon cancer is treatable if caught early, The American Cancer Society recommends screening for colorectal cancers starting at age 45 for people considered an average risk. Screening for the disease may be done using a stool-based test or a visual examination of the colon through a procedure such as a colonoscopy. Although Medicare does cover colonoscopy, how often they’ll reimburse for the procedure depends on your risk level. Keep reading to gain a basic understanding of this routine exam and learn about Medicare’s guidelines when it comes to coverage.
What Is a Colonoscopy?
A colonoscopy is a diagnostic procedure that’s used to screen for abnormalities or changes in the colon and rectum. During the procedure, which is performed under light sedation and usually takes between 15 and 60 minutes, a colonoscope is inserted into the rectum. This long, flexible tube has a tiny video camera mounted to its tip, which lets the physician see inside of the colon. The scope also lets the doctor remove polyps or other abnormal tissue samples to send to a lab for biopsy.
Colonoscopies may be used to screen for colon cancer, check for polyps or help physicians diagnose the cause of the following symptoms:
- Frequent abdominal pain, aches or cramps
- Chronic constipation
- Recurring diarrhea
- Changes in bowel movements
- Blood in the stool
- Unexplained weight loss
- Rectal bleeding
You can generally expect to find out the results of any biopsies within about a week.
Does Medicare Cover a Colonoscopy?
Yes. If the doctor performing the procedure accepts Medicare assignment, Original Medicare covers the payment for a colonoscopy. There is no minimum or maximum age limit. However, if your physician recommends a colonoscopy more often than Medicare allows, you may be responsible for some or all of the cost. Medicare Advantage plans also cover the cost of colonoscopies.
How Often Does Medicare Pay for a Colonoscopy?
How often Medicare pays for a colonoscopy depends on your risk level. If you’re at a higher risk for colorectal cancer due to a family history or other factors, Medicare pays for you to have a screening colonoscopy every 24 months. If you’re at average risk for the disease, Medicare pays for you to undergo testing every 120 months.
Risk factors may include but are not limited to the following:
- A family history of colorectal cancer
- A personal history of inflammatory bowel disease (IBD)
- Prior polyp removal
What Is the Cost of a Colonoscopy With Medicare?
If a colonoscopy is performed by a Medicare-approved physician and you stick to Medicare’s reimbursement schedule, Medicare beneficiaries pay nothing for a colonoscopy. There is no copay or coinsurance, and the Part B deductible does not apply.
Does Medicare Pay for Colonoscopy Anesthesia?
Yes, Medicare pays for all costs associated with a screening colonoscopy procedure, including anesthesia.
Are There Other Costs You May Be Responsible for?
If polyps or other abnormal tissue are found and removed during the procedure, you may be required to pay a hospital copay and 20% of the Medicare-approved amount for your physician’s services. This amount may be affected by the individual facility and any private insurance you may have.
Original Medicare also doesn't pay for colonoscopy preparation kits, which are required for emptying your bowels prior to the procedure. However, these prep kits may be covered through Medicare Part D or Advantage plans that include prescription drug coverage.
Is There an Alternative to Having a Colonoscopy?
Yes. For individuals who wish to avoid having a colonoscopy, there are actually several alternatives available:
- Flexible sigmoidoscopy: Although this procedure still involves the insertion of a tube into the rectum, it only looks at the rectum and lower colon and doesn’t require sedation. However, it still requires a traditional preparation prior to the procedure.
- Virtual colonoscopy: Using a quick CT scan to provide a view of the inside of the colon, a virtual colonoscopy is a less-invasive alternative to a traditional colonoscopy. It still requires traditional prepping beforehand to empty the colon.
- Stool testing: For stool testing, you must obtain a small stool sample, which is sent to a lab for fecal immunochemical testing and/or DNA analysis. Cologuard is a simple at-home stool-collection kit that’s designed to be used every three years. However, it isn’t recommended for individuals with an increased risk of colorectal cancer or those who are exhibiting symptoms such as bleeding or undiagnosed abdominal pain.
- Colon capsule testing: This up-and-coming diagnostic exam involves swallowing a pill-sized camera that takes photographs of the digestive tract. Unfortunately, it isn’t currently sensitive enough to be reliable as a primary screening option, especially for individuals who have a higher-than-average risk of colon cancer.
How Much Does a Colonoscopy Cost Out of Pocket?
Typically, a colonoscopy costs between $800 and $1,600 out of pocket, and costs may vary by location, physician and the duration of the procedure. For individuals who are completely uninsured, the procedure may cost upwards of $5,000 when factoring in anesthesia, follow-up visits and facility fees.
The Patient Prevention and Affordable Care Act (PPACA) requires all insurers to cover preventative screening exams, such as colonoscopies. However, if you have private insurance, you may be required to pay a copay, coinsurance or a deductible.
Does Medicare Require Prior Authorization for a Colonoscopy?
Some Medicare Advantage plans require prior authorization before you can schedule a colonoscopy. Because plans may vary widely by provider, check with your individual Medicare Advantage carrier to find out if you’ll need pre-authorization for your exam.
At What Age Does Medicare Stop Paying for Colonoscopies?
Although many physicians believe that diagnostic colonoscopies may no longer be worth performing after an individual hits age 75, Medicare pays for the procedure regardless of age.