Medicare covers the costs of screening colonoscopies at specific time intervals, based on a person’s risk for colorectal cancer. For those with Medicare, the test is usually free. However, a person may have to pay out-of-pocket costs if they need a polyp removal or use anesthesia services.
A screening colonoscopy plays a vital role in identifying colorectal cancer and providing a person with treatment opportunities early in the progression of the disease.
In 2012, approximately 15 million colonoscopies took place across the United States. Health authorities in the U.S. are currently aiming to perform screening for 80% of people aged 50–75 years by the year 2024.
This target may not be achievable, however, as many people cannot afford a colonoscopy. Medicare may remedy this by making colorectal cancer screening more accessible for those with an increased risk, such as older adults.
In this article, we explain how Medicare covers colonoscopy costs and what a person can expect to pay out of pocket for the procedure.
Doctors use a colonoscopy to look for disease, changes, or abnormalities in the colon and rectum. A person with no symptoms may have a screening colonoscopy as a preventive measure, whereas someone with symptoms may undergo a diagnostic colonoscopy that also involves tissue sampling.
The type of colonoscopy will determine the extent of Medicare coverage.
Medicare covers screening colonoscopy costs as long as the doctor who performs the test accepts assignment.
Accepting assignment means that they agree to Medicare reimbursing them at a standard rate for screening colonoscopies.
Medicare will cover screening colonoscopies at the following intervals:
- Once every 24 months: This interval is for people who have a higher-than-average risk of colorectal cancer due to a family or personal history of the disease.
- Once every 48 months: Medicare will fund this after a person has had a flexible sigmoidoscopy. In this examination, the doctor inserts the colonoscope into the sigmoid colon but no deeper.
- Once every 120 months: People who are not at increased risk of colorectal cancer will get coverage for a test every 10 years.
If a doctor accepts assignment and the colonoscopy is straightforward, a person with Medicare does not pay anything for the test.
However, if the doctor views or removes polyps or other tissue during the procedure, the colonoscopy becomes a diagnostic rather than a screening procedure, and different coverage rules apply.
Polyps are growths in the lining of the rectum and colon. Although many polyps are not cancerous in the beginning, they may become cancerous over time. It is challenging for a doctor to predict the presence of polyps before a colonoscopy, and they are usually so tiny that a person will not be aware of them. For this reason, colorectal cancer screenings are essential.
An estimated one-third of people receiving a colonoscopy do so under anesthesia. This means that the doctor gives them sedation that makes the procedure easier to tolerate by preventing pain and discomfort.
In 2015, the Centers for Medicare & Medicaid Services (CMS) announced that they would not charge people a copayment or apply a deductible for Medicare enrollees who received anesthesia during a routine colonoscopy. The CMS expanded this coverage in the hopes of incentivizing more people to get a colonoscopy.
During a diagnostic colonoscopy, a doctor removes polyps or takes tissue biopsies.
A person with Medicare will need to cover 20% of the Medicare-approved amount of the doctor’s services, as well as a copayment if the doctor performs the procedure in a hospital setting.
Although Medicare funds colonoscopy under its Part B plans, the Part B deductible does not apply.
If a doctor thinks that Medicare will not cover a person’s colonoscopy costs, they must provide the individual with an explanation called an Advance Beneficiary Notice of Noncoverage (ABN).
If a doctor identifies a polyp or several polyps, they will likely advise the person to return for another colonoscopy on a specific date rather than waiting another 10 years. This colonoscopy will be diagnostic and not routine.
As a result, a Medicare enrollee may be responsible for costs that include:
- anesthesia services
- physician services
- hospital facilities
- laboratory testing of the polyp for cancer
Although undergoing a diagnostic colonoscopy has some financial impact, it is important to remember that the cost of treating colorectal cancer is much higher than that of preventive screening.
Using a colonoscopy to identify and remove precancerous growths before they progress and become malignant is a vital part of colorectal cancer prevention.
During a colonoscopy, a doctor examines the large intestines by inserting a thin, flexible scope into the rectum and advancing it through the colon. The scope has an illuminated camera that collects images of the lining of the large bowel and identifies any unusual growths, or polyps.
A colonoscopy can help doctors screen for colorectal cancer and remove polyps to help prevent this disease.
As colorectal cancer is the third leading cause of cancer death in the U.S., colonoscopies can enable lifesaving treatment in the early stages of cancer.
Adults should begin colorectal cancer screenings at the age of 50 years and continue regular screenings until they turn 75. A person with a family history of colorectal cancer may benefit from earlier screenings.
Not all colonoscopies are for cancer screening. A colonoscopy can also be a diagnostic procedure to identify different causes of active gastrointestinal (GI) symptoms.
For example, doctors may use colonoscopies to diagnose or monitor the following health issues:
- underlying GI symptoms, such as diarrhea, bloating, or changes in stool habits
- inflammatory bowel diseases (IBD), including ulcerative colitis and Crohn’s disease
- bleeding from the rectum or blood in the stool
Whether a colonoscopy takes place for screening or diagnostic reasons may affect whether a person can get Medicare reimbursement.
If a doctor recommends a colonoscopy, understanding the reason behind the referral can provide some clarity when it comes to coverage and out-of-pocket costs.
If a doctor accepts assignment, Medicare covers the cost of standard screening colonoscopies.
If a doctor has to remove polyps from a person’s colon or rectum, the procedure becomes a diagnostic colonoscopy, and the individual may be responsible for some costs. These include 20% of the Medicare-approved amount, as well as a copayment if the procedure takes place in the hospital.
A doctor is responsible for providing individuals with an explanation called an ABN if they have reason to think that Medicare will not cover colonoscopy costs.