Does Medicare Cover a Colonoscopy?
A colonoscopy enables your doctor to view the inside of your colon and rectum. The procedure is usually performed by a gastroenterologist on an outpatient basis, primarily to detect or diagnose colon or rectal cancer or other serious conditions.
Colon cancer and rectal cancer have many features in common. The overarching term is colorectal cancer. When precancerous growths and colorectal cancer are found early, treatment tends to be the most effective.
Medicare Benefits Solutions
Dec 1, 2021
3 minutes read
The American Cancer Society (ACS) “recommends that people at average risk of colorectal cancer start regular screening at age 45.” Between 2013 and 2017, colorectal cancer dropped about 1% annually, mostly among older adults. The ACA attributes the declining rate to healthy lifestyle changes and screenings. Medicare benefits include various types of colorectal cancer screenings.
Colorectal cancer screenings
Medicare Part B covers colonoscopy screenings according to the following schedule:
- Every 10 years, no minimum age requirement
- Every 24 months, if you are in a high-risk category
- Every 48 months, if you have previously had a flexible sigmoidoscopy
Medicare also covers these screenings:
- Multi-target stool DNA test
- Fecal occult blood test
- Flexible sigmoidoscopy
- Barium enema
Routine colonoscopies are at no cost to you if you use a participating Medicare health care provider. Participating providers must accept the Medicare-approved amount paid to them directly.
In the course of a routine procedure, your doctor may find and remove a polyp. In that case, you may be responsible for:
- 20% of the cost for your doctor’s services based on the Medicare-approved payment
- Copayment to the hospital outpatient facility
Diagnostic colonoscopy
Your doctor may prescribe a colonoscopy if you experience one of the following:
- Anal bleeding
- Bowel changes
- Abdominal pain
- Weight loss not attributable to other causes
If your doctor orders a diagnostic colonoscopy versus a preventive screening, your Medicare benefits may fall under outpatient surgery. In that case, you are responsible for the Part B deductible as well as the 20% coinsurance and hospital outpatient facility copay.
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The cost of a colonoscopy
Your cost may vary with the:
- Technique, such as snare, endoscope, biopsy forceps, or band ligation
- Purpose, for example, screening versus removal of a polyp, tumor, or other lesions
If you have Part B, the following examples apply when you use participating doctors and outpatient settings. These are national average out-of-pocket costs paid to the facility and physician:
- Low-risk screening of the large bowel using an endoscope: $0
- Removal of a lesion using a sigmoidoscope through which the doctor inserts a thin metal snare: $155 if done in an ambulatory surgical center or $258 if done in a hospital outpatient unit
Resources
If you have Medicare Advantage, review your plan materials to determine the benefits and out-of-pocket costs that apply to your plan.
To research colorectal procedures, you may want to include these resources in your research:
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