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Is Medicare Cover Extended to Colonoscopies?

Updated: Oct 28, 2023


Colonoscopies allow doctors to check for colorectal polyps or cancer. They are an essential screening tool to detect colon cancer early, when it is most treatable. Medicare provides coverage for colonoscopy procedures under certain circumstances.


Below we’ll look at Medicare’s coverage specifics for screening and diagnostic colonoscopies. Understanding the rules can help you get the testing you need while minimizing out-of-pocket costs.


Medicare Coverage for Colorectal Cancer Screenings

Original Medicare Part B covers a variety of colorectal cancer screening tests including:

  • Colonoscopy - every 24 months for high-risk individuals; every 10 years otherwise

  • Fecal occult blood test - every 12 months

  • Flexible sigmoidoscopy - every 48 months

  • Cologuard DNA testing - every 3 years

For screening colonoscopies, Medicare Part B covers the full cost as long as you see a provider who accepts Medicare assignment. You pay nothing as long as your doctor codes it properly as a preventive screening colonoscopy.


When Diagnostic Colonoscopies Are Covered

In some cases a screening colonoscopy may transition into a diagnostic procedure during the procedure itself, like if a doctor finds and removes a polyp for biopsy.


Medicare still covers diagnostic colonoscopies but you may have to pay the Part B deductible and coinsurance. Coverage levels depend on your symptoms and medical history. Talk to your doctor to understand the coding being used to avoid surprise bills.


Medicare Advantage Coverage for Colonoscopies

Medicare Advantage Plans must cover colonoscopies without cost sharing when used as a preventive screening test same as Original Medicare.


For diagnostic colonoscopies, your out-of-pocket costs may be lower with Medicare Advantage since many plans have annual caps that limit your spending. Costs will vary by plan.


When Medicare May Not Cover Colonoscopy Costs

There are certain situations where Medicare will not cover the full cost of a colonoscopy:

  • If your doctor bills a screening procedure as diagnostic without proper cause

  • Colonoscopies done more frequently than the coverage timeframes allow

  • When performed by an opt-out or non-participating Medicare provider

  • If coded improperly by your provider

Make sure your provider follows Medicare guidelines to avoid unexpected bills. Getting an Estimate of Costs form ahead of time can protect against surprise charges.


Should You Get Screened for Colorectal Cancer?

Talk to your doctor about the right colorectal cancer screening schedule for you based on your personal risk factors and family history.


When used as recommended, Medicare provides vital coverage to help beneficiaries get potentially life-saving colon cancer screening without financial barriers. Take advantage of these benefits to stay healthy.


We’re Here to Help

You do not have to spend hours reading articles on the internet to get answers to your Medicare questions. Give the licensed insurance agents at Lane Financial Strategies a Call at (804) 897-2170. You will get the answers you seek in a matter of minutes, with no pressure and no sales pitch. We are truly here to help.


FAQs


Does Medicare cover extended to colonoscopies?

Yes, Medicare does cover colonoscopies. It is considered a preventive service that helps detect and prevent colon cancer.


What is a colonoscopy?

A colonoscopy is a procedure that allows a doctor to examine the entire length of the colon using a flexible tube with a camera at the end. It is used to detect any abnormalities or signs of colon cancer.


Are all colonoscopies covered by Medicare?

Medicare covers colonoscopies that are considered to be preventive screenings. However, if a colonoscopy is performed for diagnostic purposes or for surveillance of a known condition, it may not be fully covered.


How often can I have a colonoscopy covered by Medicare?

Medicare covers a screening colonoscopy once every 10 years or every 120 months for most beneficiaries. However, if you have a high risk for colorectal cancer, Medicare may cover a colonoscopy once every 24 months.


What are the criteria for Medicare to cover a colonoscopy Procedure?

Medicare will cover a colonoscopy if you are 45 years or older, have a personal history of colorectal cancer or polyps, or have a family history of colorectal cancer. Medicare will also cover a colonoscopy if you are at high risk for developing colorectal cancer.


What is the cost of a colonoscopy Screening?

Medicare pays for 80% of the Medicare-approved amount for a screening colonoscopy. If any polyp or other tissue is found and removed during the procedure, there may be additional costs.


Do I have to pay anything for a Medicare-covered colonoscopy?

If you have Original Medicare, you normally don't have to pay anything for a colonoscopy screening. However, you may have to pay a 20% coinsurance if any tissue is found and removed during the procedure.


What if my health care provider does not accept Medicare assignment?

If your health care provider does not accept Medicare assignment, you may have to pay the full cost of the colonoscopy upfront. It is important to choose a health care provider that accepts Medicare assignment to ensure full coverage.


Can I have a colonoscopy at a hospital outpatient setting?

Yes, Medicare covers colonoscopies performed at a hospital outpatient setting. However, it is important to check with your insurance plan to ensure that the hospital and health care provider accepts or are both Medicare-approved.


How do I know if Medicare covers colonoscopy for me?

You can contact Medicare or your insurance plan to determine if a colonoscopy is covered for you. It is also a good idea to consult with your health care provider to assess your specific risks and needs.

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