Medicare Coverage for Diagnostic Colonoscopy

October 28, 2019

• Medicare

A colonoscopy is a test that uses a small camera to scan your entire colon to detect disease before it becomes a catastrophic health issue.

Colorectal cancer, also called colon cancer, is the third most common cancer among adults in the United States, according to the Centers for Disease Control.

Does Medicare Cover Colonoscopy?

Medicare can cover some or all of the costs surrounding your colonoscopy. How much you pay depends on what the test finds and whether the test is considered to be a screening colonoscopy or a diagnostic colonoscopy.

Screening Colonoscopies

Medicare Part B covers preventive screenings, tests, and x-rays, including screening colonoscopies. Original Medicare covers screening colonoscopies in full if your doctor or health care provider agrees to perform the test. The coverage you get depends on your risk for developing cancer.

If you have a high risk for developing colon cancer, you get coverage for:  

• One screening colonoscopy every two years

If you have an average risk of developing colon cancer, you get coverage for:

• One screening colonoscopy every 10 years
• Or one screening colonoscopy four years after a flexible sigmoidoscopy (a similar test to a colonoscopy, however, it only examines the lower part of the colon

Diagnostic Colonoscopies

If the screening colonoscopy reveals a polyp or other cancer tissue and your doctor removes it, then the test becomes a diagnostic colonoscopy.

Medicare coverage for a diagnostic colonoscopy differs from a screening colonoscopy. You might be responsible for paying 20 percent of the Medicare-approved total cost of the procedure along with the Medicare Part B deductible, which is $185 in 2019.

Does Medicare Pay for Colonoscopy Anesthesia?

How much you’ll pay for anesthesia depends on whether your colonoscopy is for screening or diagnostic purposes. Medicare coverage for diagnostic colonoscopy anesthesia comes with both a 20 percent coinsurance fee and the Part B deductible. S

ince a screening colonoscopy is considered preventive care, Medicare waives any coinsurance fees and the Part B deductible that normally goes with anesthesia.

Does Medicare Cover Virtual Colonoscopy?

A virtual colonoscopy (CT colonoscopy) uses a computer rather than a camera to scan the large intestine. According to the American Cancer Society, Medicare “does not cover virtual colonoscopies at this time.”

What Other Colon Cancer Tests Does Medicare Cover?

Sometimes people will use other tests to screen for colon cancer. Medicare will cover the following preventive screening tests if you’re 50 or older:

• Cologuard (stool DNA test): Once every three years for people ages 50 to 85 who do not display colon cancer symptoms and who have an average risk of colorectal cancer. A stool DNA test can show altered DNA and/or blood in the sample, and those results may mean you have cancer.
• Fecal Occult Blood Test (FOBT) or Fecal Immunochemical Test (FIT): For people 50 and older once per year. The FOBT or FIT is a lab test that checks stool samples for occult (hidden) blood. The hidden blood may signify that the colon has polyps or cancer.
• Screening Barium Enema: An X-ray that involves using a white liquid called barium to enhanced photos of the colon.

Your doctor may order a diagnostic colonoscopy if any of the above tests yield abnormal results. The diagnostic colonoscopy costs will apply.

Medicare Genetic Testing for Colon Cancer

Some people are more likely to develop cancer than others. The BRCA1 and BRCA2 gene mutations indicate a higher likelihood of developing cancer and passing the disease on to your children.

Medicare will pay for genetic testing for colon cancer if the test is medically necessary. In order for Medicare to pay for your genetic testing, you must have a high risk for developing the disease and have a personal history of cancer.

What Does Medicare Consider High Risk for Colon Cancer?

The Centers for Medicare and Medicaid Services (CMS) consider people to be high-risk if they have or have had any of the following:

• A personal or family history of colon cancer
• A personal history of inflammatory bowel disease such as Crohn’s Disease
• A sibling, parent or child who’s had colon cancer or an adenomatous polyp
• A personal or family history of adenomatous polyposis

Medicare and Colon Cancer Treatment Coverage

People who have certain qualifying diseases such as colon cancer may qualify for Chronic Special Needs Plans (C-SNPs). Most C-SNPs are Medicare Advantage plans, which are private insurance plans that may cover more cancer treatment services than Original Medicare.

A colon cancer diagnosis qualifies you for the Special Enrollment Period (SEP), which means you won’t have to wait for certain times of the year to change your coverage or enroll in new coverage. The SEP allows you to add or remove coverage as your needs change.

Find Medicare Coverage for Diagnostic Colonoscopy

Getting Medicare coverage for a screening or diagnostic colonoscopy might be a huge factor in finding colon cancer before it’s too late. If you need quality health insurance, Medicare Plan Finder can help. Call us at 844-431-1832 or fill out this form today.

This post was originally published on May 2, 2019, and updated on October 28, 2019.