Colonoscopy and Insurance: Screening or Diagnostic

With changes in the health care laws, many insurance companies, including Medicare, are required to cover the entire cost of preventative services, such as a colonoscopy.

Screening Colonoscopy

A screening colonoscopy is performed for patients who do not have any symptoms (such as blood in the stool, anemia, abdominal pain, change in bowel habits), and are of the recommended age for screening (generally above the age of 50), who do not have a history of colon cancer or colon polyps, and are getting a colonoscopy at the recommended screening interval (every 10 years). If you are at a higher risk for colon cancer, such as if you have a family history of colon cancer, the insurance company may or may not consider the colonoscopy to be a screening procedure. If you had a colonoscopy less than 10 years ago, if you are younger than 50, if you have symptoms, or if you have had colon cancer or colon polyps in the past, your insurance company may not consider a colonoscopy to be a screening procedure.

Many times, at the time of the screening colonoscopy, a polyp may be found or a biopsy taken. Generally if the original indication for the colonoscopy was for screening, it will still count as a screening even if the biopsy is done, however this varies with different insurance companies. You may be required to pay deductibles or copays for pathology or lab services.

Diagnostic Colonoscopy

A diagnostic colonoscopy is done because of worrisome symptoms, such as blood in the stool, abdominal pain, anemia, or change in bowel habits.

Surveillance Colonoscopy

A surveillance colonoscopy is generally done in patients who have a personal history of polyps of cancer or another diagnosis, and is being performed more frequently than every 10 years. Insurance companies differ as to whether they consider this to be screening or diagnostic.

Insurance Coverage Reminder

We strongly encourage patients to check with their insurance company to verify details of coverage. It is ultimately your responsibility to follow your health insurance guidelines and restrictions for your plan including participating/preferred providers, facilities and out-of-pocket expenses and deductibles.