Medicare covers colonoscopies that are performed for routine screening and for the diagnosis of symptomatic patients. How often the procedure is covered — and whether you’ll have to pay part of the costs — depends on various factors.
Colonoscopy is recommended for all people ages 50 to 75 who are at average risk of colorectal cancer, as well as for some younger and older patients at high risk. It’s a very important test: The American Cancer Society projects that about 150,000 people in the United States will receive a diagnosis of colorectal cancer in 2021, and the disease is the third-ranked killer among cancers. Colonoscopies save lives with greater success when precancerous polyps are removed during the procedure and when cancer is discovered and treated early.
Screening vs. diagnostic colonoscopies
People without symptoms undergo a screening colonoscopy for prevention, while those with symptoms may have a diagnostic colonoscopy that involves tissue sampling.
Medicare Part B covers screening colonoscopies once every 10 years for people at average risk. For those with elevated risk of colorectal cancer, Medicare covers a screening colonoscopy as frequently as every two years.
For people with symptoms that could indicate colorectal cancer, a colonoscopy is considered diagnostic, and Medicare covers the procedure differently, as described below.
Here’s the catch with Medicare’s distinction between screening and diagnostic colonoscopies: If, during a screening colonoscopy, the doctor removes polyps — abnormal growths that may be precancerous — or sees tissue that might be cancerous, the colonoscopy morphs into a diagnostic procedure. Different coverage rules kick in, and your out-of-pocket cost may rise from zero to hundreds of dollars.
Screening colonoscopy: What you’ll pay
Fees for colonoscopies typically range from many hundreds of dollars to several thousand dollars. Services provided during colonoscopy can include the physician’s fee, anesthesia, hospital or surgicenter facility fees and biopsy of any tissues removed.
The good news is that you pay nothing for a screening colonoscopy if your doctor or other qualified health care provider accepts Medicare. Medicare Part B covers colonoscopy, but the Part B deductible doesn’t apply to this procedure.
Diagnostic colonoscopy: What you’ll pay
If a polyp or other suspicious tissue is found — and possibly removed — during your colonoscopy, you may pay 20% of the Medicare-approved amount for the procedure. That 20% is likely to translate to hundreds of dollars that you’ll owe, though again the Part B deductible doesn’t apply.
Medicare Advantage plans offered in some states may reduce your out-of-pocket cost for a diagnostic colonoscopy.
With so many cost variables, it makes sense to ask your gastroenterology practice what you could end up paying out of pocket if your colonoscopy is categorized as diagnostic.