Does Medicare Cover a Colonoscopy?
If you are at high risk for colorectal cancer, Medicare will cover a screening colonoscopy every 24 months. If you’re not at high risk, Medicare will pay for a colonoscopy once every 120 months or every 48 months if you’ve had a flexible sigmoidoscopy, or an examination of the lower colon.
What Is a Colonoscopy?
A colonoscopy is a minimally invasive examination of the large intestine used to screen for colon cancer. The preventive screening usually takes 30 minutes to an hour.
A doctor inserts a thin, flexible tube called a colonoscope into the rectum. A small video camera on the tip of the scope allows the doctor to see the inside of the entire colon.
The examination can detect colon cancer. The doctor can also use the colonoscope to remove polyps to prevent colorectal cancer.
Who Needs a Colonoscopy?
The U.S. Preventive Services Task Force recommends that people at average risk of colorectal cancer should have regular colonoscopies starting at age 50. The American Cancer Society recommends people start screening at 45.
The USPSTF concluded that colonoscopies provide a “substantial benefit” to people aged 50 to 75. But it found that a colonoscopy may not be as beneficial to people 76 to 85 who’ve had previous screenings.
Colorectal cancer is most often diagnosed in people from 65 to 74 years old, and the average age of death from the disease is 73.
What Colonoscopy Costs Does Medicare Cover?
If the doctor removes polyps or other tissue during the procedure, Medicare will pay 80 percent of the Medicare-approved cost.
You will be responsible for the other 20 percent of costs. You will also be responsible for any copayment if the screening happens in a hospital setting. Your Medicare Part B deductible will not apply.
Medicare does not cover a CT colonography — sometimes called a “virtual colonoscopy.”
Not all colonoscopies are for colon cancer screenings. Medicare may not fully cover these examinations. You should check with your doctor about the nature of your colonoscopy and with Medicare or your Medicare Advantage insurer about coverage and out-of-pocket costs.
- Diagnosing symptoms, including diarrhea and bloating.
- Diagnosing the reason for blood in the stool or bleeding from the rectum.
- Monitoring or diagnosing irritable bowel disease (including Crohn’s disease and ulcerative colitis).
High Risk vs. Average Risk of Colonoscopies
Medicare has covered screening colonoscopies for people at average risk of colorectal cancer since 1998.
Average risk is defined as anyone who does not fit into higher risk categories. About 75 percent of people who develop colorectal cancer are considered part of that average risk group, according to the journal American Family Physician.
- No colorectal cancer symptoms
- No personal history of colorectal cancer
- No personal history of polyps
- No family history of colorectal cancer
- No unexplained anemia
- No inflammatory bowel disease such as Crohn’s disease or ulcerative colitis
Higher risk individuals are those who have any of these listed conditions, medical histories or symptoms.
Medicare’s screening colonoscopy coverage varies based on whether you are at average or high risk for developing colorectal cancer.
- Once every two years for people at high risk of colorectal cancer
- Once every 10 years for people at average risk
- Once, four years after a flexible sigmoidoscopy screening for people at average risk
Which Parts of Medicare Cover Colonoscopies?
Different parts of Medicare may or may not cover your colonoscopy. Each part provides different kinds of coverage for different medical services.
- Medicare Part A (Hospital Insurance)
- Covers a colonoscopy if you need one while you are hospitalized (Part B would cover your doctor’s services). You may have to pay a copayment or deductible.
- Medicare Part B (Medical Insurance)
- Medicare Part B covers the costs of outpatient colorectal cancer screening colonoscopies. Part B pays the full cost whether or not you’ve met your deductible for the year. You will have to pay 20 percent of costs for removal of polyps or other tissue.
- Medicare Part C (Medicare Advantage)
- Federal law requires Medicare Advantage plans to cover screening colonoscopies. You need to make sure your doctor and anesthesiologist are in your plan’s network to avoid out-of-pocket costs.
- Medicare Part D (Prescription Drug Plans)
- Medicare Part D prescription drug plans may cover prescriptions for bowel preparation prior to a colonoscopy. Check with your Part D plan to determine what is or is not covered.
- Medicare supplemental insurance plans may help with out-of-pocket expenses if your doctor removes polyps or other tissue during a colonoscopy. Check with your Medigap plan to determine what it covers.
Other Colon Cancer Screenings Medicare Covers
Colonoscopies are one of several colorectal cancer screening tests that Medicare covers. Coverage varies for other types of tests.
- Flexible Sigmoidoscopy
- Medicare covers at no cost to you so long as the procedure is done as a cancer screening. If the procedure requires a biopsy or removal of a polyp or other tissue, you will have to pay 20 percent of the cost.
- These are tests that measure blood in the stool that can’t be seen with the naked eye. Medicare covers these at no cost — no coinsurance or Part B deductible — for people 50 and older.
- Stool DNA Test (Cologuard)
- Medicare covers at no cost for people 50 to 85 as long as you are not at increased risk of colorectal cancer and don’t have symptoms.
- Double-Contrast Barium Enema
- You are responsible for 20 percent of the Medicare-approved cost for doctor services. If done in a hospital setting, you may also have to pay the hospital’s copayment. You do not have to pay the Medicare Part B deductible, though.
8 Cited Research Articles
- Medical News Today. (2020, March 9). Does Medicare Cover Colonoscopy? Retrieved from https://www.medicalnewstoday.com/articles/does-medicare-cover-colonoscopy
- AARP. (2020). Does Medicare Cover a Colonoscopy? Retrieved from https://www.aarp.org/health/medicare-qa-tool/does-medicare-cover-a-colonoscopy/
- American Cancer Society. (2018, February 21). Insurance Coverage for Colorectal Cancer Screening. Retrieved from https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/screening-coverage-laws.html
- Andrews, M. (2018, January 30). After Polyps Are Detected, Patients May No Longer Qualify for Free Colonoscopies. Retrieved from https://khn.org/news/after-polyps-are-detected-patients-may-no-longer-qualify-for-free-colonoscopies/
- U.S. Preventive Services Task Force. (2016, June 15). Colorectal Cancer: Screening. Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/colorectal-cancer-screening#bootstrap-panel--2
- Read, T.E. and Kodner, I.J. (1999, June). Colorectal Cancer: Risk Factors and Recommendations for Early Detection. Retrieved from https://www.aafp.org/afp/1999/0601/p3083.html
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Screening Colonoscopies. Retrieved from https://www.medicare.gov/coverage/screening-colonoscopies
- Mayo Clinic. (n.d.). Colon Cancer. Retrieved from https://www.mayoclinic.org/diseases-conditions/colon-cancer/symptoms-causes/syc-20353669