Does Medicare Cover a Colonoscopy?
Yes, Medicare covers screening colonoscopies. How often these screenings are covered depends on your risk of colorectal cancer, and how much you may pay depends on what the screening finds and where you have the screening done.
Keep reading to learn more about Medicare coverage for colonoscopies, including eligibility requirements, screening frequencies, costs, and the different types of colorectal cancer screenings.
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What Is a Colonoscopy?
A colonoscopy is an exam for detecting injury or illness in the colon, also called the large intestine, and the rectum. Doctors use a long, flexible tube with a camera attached to the end to perform a colonoscopy. This tube is inserted into the rectum, where doctors check for issues such as swelling, irritated tissue, polyps, or signs of disease such as colorectal cancer or inflammatory bowel disease. During the exam, abnormal tissues can be removed, and tissue samples, also called biopsies, may be taken.
Colonoscopies are an essential part of colon cancer screening and prevention. One in 24 Americans develop colon cancer in their lifetimes, and colorectal cancer is the second deadliest cancer in the country. In addition, colon cancer may not come with any obvious symptoms, making colon screenings vital for detecting this type of cancer before it spreads.
What Is Medicare Coverage for a Colonoscopy?
Medicare Part B covers colonoscopies on a set schedule. The interval between covered colonoscopies depends on your risk of colorectal issues and your most recent exam data.
Medicare also covers flexible colonoscopy screenings if you have received a positive result from a non-invasive test, such as a fecal occult blood test or a multi-target stool DNA test.
You are eligible for a diagnostic colonoscopy once every 24 months if you are at high risk of colon cancer. High-risk individuals include those with a history of colorectal cancers or bowel diseases, a first degree relative who had colorectal cancer, or a family history of symptoms related to this type of cancer, such as Lynch syndrome.
How Often Does Medicare Pay for a Colonoscopy?
Medicare covers a colonoscopy every 120 months or ten years if you are not considered high-risk. In addition, it covers this exam 48 months after you’ve had a sigmoidoscopy, which also uses a flexible camera but examines only the lower third of the colon.
Medicare also covers some other types of colorectal cancer screening at different frequencies.
- Cologard: Every three years for low-to-moderate risk patients.
- Sigmoidoscopy: Every four years for patients 45 and older.
- Barium Enema: Every two years for high-risk patients and every four years if used in place of a sigmoidoscopy or colonoscopy.
- Fecal Occult Blood Test: Every year for patients 45 and older.
- Multi-target Stool DNA Test: Every three years for low-to-moderate risk patients.
- Computed Tomography (CT) Colonography: Not covered under Medicare.
How Much Would a Colonoscopy Cost With Medicare?
Under Medicare, Part B coverage pays for your colonoscopy. The Part B deductible does not apply for this procedure, meaning you pay nothing out of pocket for your scheduled exam.
However, there are situations where costs may apply. First is if your doctor finds and removes a polyp or other tissue from your colon during the exam. In this case, you pay 15% of the Medicare-Approved amount for the service. If your exam occurs in a hospital outpatient facility or an ambulatory surgical center, you also pay 15% coinsurance.
Other factors that may impact what you pay out of pocket include any other health insurance you may have, if your doctor accepts the Medicare assignment for payment, and how much your doctor charges for the process.
There may also be situations where your doctor recommends exams more often than Medicare covers. In this case, Medicare may cover some or none of the costs, depending on the doctors’ reason for the exams and your coverage. For example, if you have a Medicare Advantage plan through a private insurer, your plan might include additional coverage for colonoscopy exams.
Colonoscopies vs. Other Colorectal Cancer Screenings
Along with screening colonoscopies, other types of colorectal cancer screening can help detect the early stages of this disease. The various types of screening provide different information and are carried out in distinct ways. For instance, some use non-invasive scanning techniques or ask patients to bring in stool samples, while others use the insertion of flexible cameras.
Medicare covers multiple screening options for those over 45 years old or at high risk of developing colorectal cancer. However, Medicare does not cover computed tomography (CT) colonography. Some Part C, or Medicare Advantage plans, may cover this procedure, so it’s worth checking your policy details if you have a Part C plan and want a CT colonography.
Here’s a look at what Medicare covers for each type of screening:
- Cologuard: 100% covered.
- Colonoscopy: 100% covered.
- Sigmoidoscopy: 100% covered.
- Barium Enema: Medicare covers 80% of the Medicare-approved amount.
- Fecal Occult Blood Test: 100% covered.
- Multi-target Stool DNA Test: 100% covered.
- CT Colonography: Not covered.
How Different Types of Colorectal Cancer Screenings Work
Each type of colorectal cancer screening works differently. Here’s a more in-depth look at each.
- Cologuard: This take-home is provided by a doctor or laboratory. The take-home kit includes a container for stool collection, a prepaid mailing label, and instructions. Once patients have collected their samples, they send them through the mail for laboratory analysis.
- Colonoscopy: Doctors insert a flexible tube with a camera at one end into the patient’s anus. This allows them to examine the colon for signs of abnormality or disease. If something is found, it can be removed during the procedure. To help keep patients comfortable during the hour-long procedure, sedation is provided.
- Sigmoidoscopy: A sigmoidoscopy is similar to a colonoscopy in that a flexible tube is interested into the anus. Unlike a colonoscopy, however, a sigmoidoscopy only examines the lower third of the colon. This process takes 10-20 minutes, and patients may be offered local anesthetic rather than sedation.
- Barium Enema: In this procedure, a small tube is inserted into the anus. This tube contains liquid barium, which coats the colon and shows as white on X-rays, helping doctors find colon abnormalities. This test takes 30-60 minutes, and patients may be asked to shift positions to coat different parts of their colon in barium.
- Fecal Occult Blood Test: This test looks for blood in the stool. It is provided as a take-home kit with instructions for sample collection and testing. If the test results indicate blood in the stool, patients follow up with healthcare providers to determine the next steps.
- Multi-target Stool DNA Test: Another take-home test, this screening helps identify abnormal DNA in stool samples. Patients are given a kit from their doctor or a laboratory. This kit includes collection instructions and a special container that is mailed to the lab for analysis once the sample is collected.
- Computed Tomography Colonography: Sometimes called a virtual colonoscopy, this procedure uses a CT scanner to take multiple X-ray images of a patient’s colon. These images are combined into a detailed 3D representation that doctors can examine for abnormalities. This non-invasive procedure typically takes 30 minutes to an hour. CT colonography is not currently covered under Medicare, but a Medicare colonoscopy loophole for this coverage may exist if you opt for a Medicare Advantage plan.
The type of testing your doctor recommends depends on your current age, your existing health conditions, and any symptoms that may indicate a colon issue.
Putting It All Together
Medicare covers colonoscopies, but the schedule for these preventative exams depends on risk factors, including your health, age, and family history.
Other colon-related screenings, such as Cologuard tests and sigmoidoscopies, may also be covered under Medicare. Meanwhile, procedures such as CT colonography are not covered by Original Medicare but may be available as part of Medicare Advantage plans.
A colonoscopy can help discover signs of cancer or other diseases before they’re too far along to treat. Under Medicare, basic colonoscopies are 100% covered for both high- and low-risk patients and are worth doing when available.