Does Medicare Cover a Colonoscopy? 

Who doesn’t cringe when hearing the word colonoscopy? If you’re over 50, you’ve probably had one or two in your lifetime, and even if you don’t look forward to your next colonoscopy you know it’s a smart thing to do.

In the United States, colon cancer is number three on the list of most common types of cancers But it’s also one of the most preventable types of cancer, and having a colonoscopy is what makes that true.  

Physicians perform colonoscopies by inserting a tube, with a video camera attached, into the rectum. As the tube moves through the colon, the doctor can see what’s going on inside. He’s looking for swollen or irritated tissue, polyps, or signs of cancer during the examination. If he finds polyps or abnormal tissue, he can remove them and take samples for biopsies during the procedure. 

It is also common for someone to undergo a colonoscopy if they are experiencing rectal bleeding, chronic diarrhea, or abdominal pain to place a stent, or to remove an obstruction in the colon.  

You may dread the thought of having a colonoscopy, but it’s a common procedure that can save your life. And one more good thing, if you have Medicare, you most likely qualify for its coverage. 

How does Medicare cover colonoscopy procedures? 

Original Medicare Part B, which is your outpatient medical insurance, covers different types of screenings, tests, and vaccines as preventive health measures. Colonoscopy screenings are included in these Medicare benefits for preventive care. 

Original Medicare Part B covers screening colonoscopies once every 24 months for people who are at high risk for colorectal cancer. For those who don’t fit into the high-risk category, Medicare covers the colonoscopy exam once every 120 months or 48 months following a flexible sigmoidoscopy. 

Your health care provider may prescribe more frequent colonoscopies if you are in a high-risk category for colorectal cancer. Some of the most common risk factors are:

  • Age, the older you are, the higher the risk. 
  • Having inflammatory bowel disease including Crohn’s or ulcerative colitis. 
  • Having a personal history of colorectal cancer or polyps. You may also have an increased risk if you have family history to these conditions. 
  • Familial adenomatous polyposis, a genetic condition that increases risk. 
  • Living a sedentary lifestyle
  • Various dietary factors such as one low in fruit and vegetables, low fiber, high fat, high consumption of processed foods and meats. 
  • Being obese or overweight 
  • Drinking excessive amounts of alcohol
  • Using tobacco products

Original Medicare Part B pays 100 percent of the cost of your colonoscopy if you have it done by a physician or other qualified health care provider who accepts Medicare assignment. You must also have it done at a medical facility that accepts Medicare. 

However, it’s important to remember that if your physician finds and removes a polyp or tissue during the procedure, Original Medicare only covers 80 percent of the final approved cost for the physician’s services. You are responsible for the remaining 20 percent of the physician’s fees as well as a copayment for the medical facility as an outpatient. In this instance, your annual Part B deductible doesn’t apply.

If you have a Medicare Advantage (Part C) plan, you are guaranteed to have at least the same coverage as you’d have with Original Medicare Parts A and B. However, depending on the type of Part C plan you have, you may be required to use health care providers, physicians, hospitals, medical facilities, and medical suppliers that are within your plan’s network of providers. 

You may not have coverage for your colonoscopy procedure if you use providers that aren’t included in your plan, so make sure you have this information before making medical appointments.

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