Does Medicare cover a colonoscopy?

Colorectal cancer is the second most common cause of cancer death in the United States when men and women are combined, so it’s important to get screened regularly.²

The American Cancer Society (ACS) recommends people at average risk for colorectal cancer begin screening at age 45. People at higher risk may need to start screening before age 45.³

For reference, the ACS states people at higher risk are those with:⁴

• A strong family history of colorectal cancer or certain types of polyps
• A personal history of colorectal cancer or certain types of polyps
• A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease)
• A family history of a hereditary syndrome such as familial adenomatous polyposis (FAP) or Lynch syndrome
• A history of radiation to the abdomen (belly) or pelvis to treat a prior cancer

Note: If you think or know you’re at higher risk for colorectal cancer, talk to your healthcare provider about your best screening option and schedule.

The amount you’ll pay for a colonoscopy with Medicare may depend on several things like:⁵

• Other insurance you may have
• How much your doctor charges
• If your doctor accepts assignment
• The type of facility
• Where you get your test, item or service

Talk to your doctor or healthcare provider before the exam to find out how much your test, item or service will cost.

Diagnostic colonoscopies are when a polyp or other tissue is found or removed. Part B will cover some of your diagnostic colonoscopy but it may not be 100% covered.⁶

For example, you may have to pay 20% of the Medicare-approved amount of your doctor’s services. Also, if the diagnostic colonoscopy is performed in a hospital outpatient setting, you will likely pay a separate facility copayment.⁷

If you have a Medicare Advantage plan, you may have additional coverage for diagnostic colonoscopies. Contact your plan carrier to see what benefits may be available to you.

It’s important to understand your potential out-of-pocket costs before any medical procedure. In the case of a diagnostic colonoscopy, your doctor or healthcare provider must provide you with a Medicare ABN form before providing the recommended items or services.⁸

An ABN form is a written notice that Medicare may not, or will not, pay for services or items recommended by your doctor or healthcare provider. The form includes the items or services that Medicare isn’t expected to pay for, the reasons why and an estimate of the costs. An ABN allows you to clearly see your financial liability for the items or services and gives you a chance to determine your options.⁹

Some factors that may affect the total cost include:

• Diagnostic treatment
• More frequent screenings
• Deductibles
• Coinsurance
• Copays
• Out-of-pocket expenses for additional procedures

Here are some tips and information for before, during and after a colonoscopy:¹⁰

The day before:

• Prepare or clean out your colon (your doctor should tell you how).
• Avoid eating solid foods, drink only clear beverages and don’t eat or drink anything after midnight.

The day of:

• Go to your doctor’s office, clinic or hospital.
• Have someone go with you and drive you home (you may be groggy from medicine afterward).

During the procedure:

• Lie on your side during the procedure (which can take 30–60 minutes).
• Your doctor will put a tube inside your rectum and up your colon. First, air blown through the tube widens your colon to make it easier to inspect. Then your doctor looks for any polyps or other growths that could be cancer. If anything is found, your doctor will explain the situation to you and your options for treatment.

After the procedure:

• You’ll rest in the recovery room and pass gas to clear the air blown into your colon.
• It’s normal to have mild cramps or a little blood in your first stool after your colonoscopy. If you bleed a lot when you poop or have severe belly pain, call your doctor. 

Unlike many cancers, colon cancer is preventable.¹¹ Regular colonoscopy screenings may help detect polyps or other growths that could be a concern and alert your doctor to remove them.

And remember—your colonoscopy screenings can be covered under your Medicare Part B coverage. If you’re unsure whether you’re due for a colonoscopy, reach out to your healthcare provider today.