Does Medicare cover a colonoscopy? Yes, and several other colorectal cancer screening tests, too



Colonoscopies for colorectal cancer screening

Several procedures are available to screen and detect colorectal cancer, which affects the colon (large intestine) or rectum. “Undergoing regular screening can lead to the detection of polyps, and removing polyps prevents cancer,” says Forman. Polyps are small growths that form on the colon’s lining. They are usually harmless, but can turn into cancer after many years.

A colonoscopy is the “gold standard” of tests to screen for colorectal cancer and can discover approximately 95% of colorectal cancers. It is also the only option that lets a gastroenterologist both find and remove colon polyps. While colonoscopies are safe procedures, they do have a small risk of tearing and bleeding.

To screen the colon during a colonoscopy, it needs to be cleaned out first. “Many people are intimidated by the bowel preparation,” says Forman. “Although not perfect, it has gotten easier. Several newer bowel preparation options require you to drink less, and the taste is a bit better. Pill preparations are also available but may not be as safe depending on your age and other medical conditions,” he says.

A colonoscopy is typically performed under sedation. During that time, a gastroenterologist will insert a colonoscope, which is a flexible tube with a camera at the end, into the rectum, and will examine the entire colon for polyps. If none are detected and the colon is adequately cleaned out, the next colonoscopy is suggested to be scheduled in 10 years.

Other colorectal cancer screening tests

Less invasive and/or less time-consuming options for colorectal cancer screening are available but aren’t as successful in finding colorectal cancer as colonoscopies.

These include fecal occult blood testing and multi-target stool DNA tests, which examine stool samples for signs of colorectal cancer, and flexible sigmoidoscopy, which only examines part of the colon. If any of these tests show a positive result for colorectal cancer, a follow-up colonoscopy is usually necessary.

Medicare coverage of colonoscopies and other colorectal cancer screening tests

Colonoscopy

If you’re at high risk for colorectal cancer, Medicare covers screening colonoscopies once every 24 months. High-risk factors include a family history of the disease, colorectal cancer or colorectal polyps, or inflammatory bowel disease. For those not at high risk, Medicare covers the test once every 120 months (10 years), or 48 months (four years) after a previous flexible sigmoidoscopy. 

Sigmoidoscopy

A flexible sigmoidoscopy is a less invasive test than a colonoscopy that only looks at the lower part of the colon. It’s covered every 48 months (four years) if you are age 50 or older and at high risk, or once every 10 years after a colonoscopy if you are 50 or older and not at high risk.

Stool-based tests

Fecal occult blood testing is covered every 12 months if you are 50 or over, and Medicare covers multitarget stool DNA tests once every three years if you are age 50-85, show no symptoms of colorectal disease, and are not at high risk for developing colorectal cancer. If you have either of these stool-based screening tests and receive a positive result, Medicare also pays for a follow-up colonoscopy.

Costs of colonoscopies and other colorectal cancer screening tests

Medicare and Medicare Advantage plans cover 100% of the costs of these procedures.

However, if your doctor detects and removes a polyp or other tissue during your colonoscopy, you’re responsible for 15% of the Medicare-approved fee for your doctor’s services. If the procedure takes place in a hospital outpatient setting or ambulatory surgical center, you will also pay a 15% coinsurance amount to the facility. 

Medicaid coverage of colorectal cancer screening is available to all states, but each state offers different types of coverage.

Medicare coverage and costs of diagnostic colonoscopies

In addition to screening, colonoscopies can be used as a diagnostic tool—such as when symptoms of colorectal cancer are present blood in the stool, weight loss, and a change in bowel habits.

During diagnostic colonoscopies, your doctor may take biopsies or remove polyps.

Diagnostic colonoscopies are generally covered at 80% on Medicare after the deductible is met. Some Medicare Advantage policies provide less expensive diagnostic colonoscopy coverage than traditional Medicare. 

If you’re considering a colonoscopy or colorectal cancer screening, don’t delay.

“It cannot be overstated: Most cases of colorectal cancer are preventable with regular screening, and screening could save your life,” says Forman.



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