If you’ve been told by your doctor that you may be at high risk for colorectal cancer, or if you’re approaching an age at which screenings for colon cancer are recommended, then you may be wondering whether or not your Medicare plan will cover a colonoscopy. The good news is that many colonoscopies are covered by Medicare Part B.
However, the amount that is covered depends on how recently you’ve had a colonoscopy, the location where you get the procedure, how much your provider charges for it, and other factors. In this article, we’ll look the circumstances in which colonoscopies are covered and how to find out if there are any additional costs that you’ll have to pay for out of pocket.
WHAT IS A COLONOSCOPY?
First, what is a colonoscopy? A colonoscopy is a medical procedure in which a small camera is inserted into the anus to examine parts of the small and large intestines. The procedure can be used to diagnose ulcers, cancers, and other growths or conditions in the bowel. It can also be used to remove small polyps in order to find out whether they are cancerous.
While a colonoscopy is not surgery, it is still an invasive procedure that requires preparation by limiting solid food intake for three days in order to clear out the bowels. Most patients receive an intravenous sedative, but some patients choose to go without sedation, as is common in some other countries such as Norway. The entire procedure takes around 30 minutes.
If polyps are found, the doctor may remove them using a tool on the endoscope so that a biopsy can be performed later. This is the riskiest part of the procedure, since a perforation of the colon can cause complications in a small number of cases. Other effects of a colonoscopy include nausea and bloating, although there is typically no long-lasting pain.
There are around 15 million colonoscopies performed in the U.S. every year, primarily in people over age 50. A less invasive procedure called a sigmoidoscopy can be used to examine issues in the part of the colon closest to the rectum. You may also be eligible for a virtual colonoscopy, in which X-rays and digital imaging tools are used in place of a physical procedure.
WHAT DO COLONOSCOPIES SCREEN FOR?
While colonoscopies are often recommended as a tool for cancer screenings, they can also be used to address other gastrointestinal issues, such as inflammatory bowel disease. That means that a colonoscopy can serve as a preventive procedure, even when there are no symptoms present, or as a diagnostic procedure used to locate and diagnose abdominal pain.
Let’s take a look at a few of the conditions a colonoscopy can screen for:
Colorectal cancer is one of the three most common types of cancer and is typically found as a tumor that grows in the colon or rectum. The risk of colorectal cancer increases with age and is influenced by diet and lifestyle rather than genetic factors. Smoking, obesity, red and processed meats, and excessive alcohol consumption can all increase the risk of colorectal cancer.
Symptoms can include constipation, loss of weight and appetite, blood in the feces, as well as nausea and vomiting. However, symptoms can vary depending on where the tumor is located, and as many as 50% of people show no symptoms at all. That’s why the CDC recommends regular screenings for people over 50 to ensure early detection of any tumors.
Up to 30% of adults have colon polyps, which can appear as flat or raised bumps in the lining of the intestine. These can be detected and removed during a colonoscopy. Although polyps are typically benign and don’t cause any symptoms, they can lead to cancer over time, so it’s important to have them diagnosed and removed promptly.
Symptoms can include rectal bleeding, diarrhea, constipation, and other abdominal issues, but many people don’t know they have polyps until they’re found during a routine screening. As with colon cancer, the risk of polyps increases with drinking alcohol, smoking, and obesity.
Inflammatory Bowel Disease
Colonoscopies can also be used to diagnose inflammatory bowel disease (IBD), which includes Crohn’s disease and ulcerative colitis (but is not to be confused with irritable bowel syndrome, or IBS). Inflammatory bowel disease can cause a variety of symptoms, including rectal bleeding, pain in the abdomen, weight loss, and anemia.
If you have unexplained symptoms that don’t clear up with over-the-counter medication, then a colonoscopy may be required to diagnose you with IBD. People with IBD are at a higher risk of developing colorectal cancer.
DOES MEDICARE COVER YOUR COLONOSCOPY?
These are just a few of the conditions that can be investigated with a colonoscopy. Whether or not Medicare covers the cost of the procedure depends on what you’re being screened for.
Colonoscopy procedures are covered under Medicare Part B under certain conditions. If you’re considered to be at high risk of colon cancer, then you’ll be covered for one colonoscopy every two years. If you aren’t, then you’ll be covered once every 10 years.
You’re considered high risk if you have:
- Symptoms of polyps or colon cancer
- An immediate relative with a history of polyps or colon cancer
- A prior medical history of polyps or colon cancer
This is in line with the CDC’s recommendation on how frequently you should be screened. It can take 10 years for a polyp to turn into cancer, so more frequent screenings aren’t recommended. Other screenings, such as stool tests and flexible sigmoidoscopy, can be used instead.
However, Medicare only covers the colonoscopy fully when it’s a preventive procedure. This is because the ACA (Affordable Care Act) eliminated copays and deductibles for preventive care. If your doctor finds a polyp and performs a biopsy, it’s considered a diagnostic and therapeutic procedure, and you will be responsible for paying the 20% coinsurance.
Unfortunately, there’s no way to know before going into the procedure whether any polyps will be found, so it’s a good idea to find out what those costs will be just in case.
HOW TO FIND OUT IF YOUR MEDICARE PLAN COVERS COLONOSCOPY
In order to find out if your colonoscopy is covered, you’ll first need to talk to your doctor to find out why he or she is recommending a colonoscopy. Is this a routine screening or a diagnostic procedure? Are you considered at high risk or low risk for colon cancer?
If you’ve had a colonoscopy before, look at your medical records to find out when it was. Has it been less than 2 years (for high risk patients) or less than 10 years (for low risk patients)? If so, you may have to wait until that period is up for your next colonoscopy to be covered.
Ask your doctor whether they charge the Medicare-approved amount (or higher), and whether the procedure will take place at the doctor’s office or a hospital setting.
Finally, call your insurer to confirm whether or not they will cover the cost of the procedure. If you have Medicare Part B, then you should be covered for a preventive screening up to the Medicare-approved amount.
If you have a Medicare Advantage or Medigap policy, you may have more comprehensive coverage, so call and ask them directly to be sure.
HOW MUCH YOU MAY HAVE TO PAY
Since there’s no way to know if a polyp will be found, it’s a good idea to assume that you may have to pay the 20% coinsurance for a therapeutic colonoscopy. If you budget for it ahead of time, you won’t be surprised by an unexpected bill when you wake up from the procedure.
The average cost of a colonoscopy is $3,081, so if you had to pay 20% coinsurance, then you would owe around $616 for the procedure. Be sure to ask your doctor what they charge, and if there are additional costs for anesthesia, lab fees, and other services.
Hopefully, no polyps will be found and your colonoscopy will be entirely covered by Medicare. If you’re a low-risk patient, you won’t have to return for another colonoscopy for 10 years.
It can be hard to find out in advance what you’ll have to pay for your colonoscopy. Your out of pocket costs could range from $0 to over $1000, depending on the purpose of your screening and what kind of Medicare coverage you have.
The good news is that even if a polyp is found, Medicare Part B will cover 80% of the cost, so you’re much better off than if you were uninsured.
If you need help finding out if your colonoscopy will be covered, or want to switch to a different policy, reach out to the team at The Medicare Store for personalized help. One of our licensed insurance agents will help you find the best coverage for you.
Just fill out our contact form here for a 15-minute phone call or in-person consultation at your home or one of our 7 Las Vegas locations. We’re here to help you get screened!