Medicare covers colonoscopies for beneficiaries aged 50 and older for colorectal cancer screening. However, there are some limitations on how often Medicare will cover the procedure. In general, Medicare provides coverage for colonoscopies every 10 years for average-risk individuals. But if you have certain risk factors, Medicare may cover colonoscopies more frequently.
When you turn 65, Medicare provides coverage for a “Welcome to Medicare” preventive visit. This visit includes a review of your medical history and current medications, and the creation of a screening schedule based on your health status and risk factors. Your doctor will make recommendations for preventive screenings, including colon cancer screening.
So when does Medicare stop paying for routine colonoscopy screenings? Here is an overview of Medicare’s coverage rules and when you may need to pay out-of-pocket for a colonoscopy.
Medicare’s Coverage of Colonoscopies
Medicare Part B covers colorectal cancer screenings including:
- Fecal occult blood tests – once every 12 months
- Flexible sigmoidoscopy – once every 48 months
- Colonoscopy – once every 120 months (10 years), or 24 months if high risk
- Barium enema – once every 48 months when used instead of sigmoid/colonoscopy
If a polyp is found and removed during the colonoscopy, Medicare will cover a follow-up colonoscopy within the next 48 months. After that, the 10 year timeline starts again.
So in general, Original Medicare provides coverage for a screening colonoscopy once every 10 years. This applies to individuals age 50 and older who do not have any other risk factors.
High Risk Individuals
Medicare may cover colonoscopies more frequently than every 10 years if you are considered high risk for colorectal cancer. High risk factors include:
- A personal history of colorectal cancer or adenomatous polyps
- A family history of colorectal cancer or polyps
- Inflammatory bowel disease (Crohn’s disease or ulcerative colitis)
- A genetic syndrome like familial adenomatous polyposis or hereditary non-polyposis colorectal cancer
If you have one of these high risk conditions, Medicare will provide coverage for colonoscopy screenings every 24 months. You will need your doctor to confirm your condition and submit documentation to Medicare explaining the need for more frequent colon cancer surveillance.
Some examples of when Medicare will cover a colonoscopy every 2 years include:
- Removing three or more polyps during a previous colonoscopy screening
- If you have a first-degree relative (parent, sibling, or child) that has had colon cancer or a polyp before age 60
- If you have had inflammatory bowel disease for more than 10 years
So Medicare provides more frequent colonoscopy coverage if you have certain high risk factors for colon cancer. The presence of polyps, family history, or bowel diseases may allow you to qualify for a screening colonoscopy every 24 months rather than every 10 years.
Surveillance Colonoscopies
Medicare also covers “surveillance” colonoscopies when needed to monitor for recurrence after treatment of colorectal cancer. Following cancer treatment, your doctor will recommend a schedule of colonoscopy surveillance based on:
- The stage of cancer at diagnosis
- The results of previous colonoscopies
- Other clinical considerations
Surveillance colonoscopies are typically recommended anywhere from every 6 to 36 months for 5 years after cancer treatment. After 5 years, these colonoscopies fall under Medicare’s screening guidelines of either every 10 years or 24 months depending on your remaining risk factors.
When Medicare Stops Covering Routine Colonoscopies
Medicare does not have an upper age limit for covering preventive services like colon cancer screening. As long as you remain enrolled in Medicare Part B, colonoscopy will be covered when screening guidelines are met.
However, studies show the most benefit from colorectal cancer screening occurs between ages 50-75. After age 75, the risks and complications associated with colonoscopy increase while the benefits decrease.
This has led some experts to recommend discontinuing routine colon cancer screening after age 75 to 85 in average-risk individuals. The decision to stop screening should be made on an individual basis after discussing the potential harms and benefits with your physician.
Some general Medicare guidelines around stopping routine colonoscopy screening include:
- Age 85 – Consider stopping routine colonoscopy screenings
- After 10-15 years of normal colonoscopies – Discuss stopping screenings with your doctor
- Life expectancy less than 10 years – Stop routine colon cancer screening
Your doctor may advise stopping colonoscopy screening if:
- You have serious or severe medical conditions that limit your life expectancy
- The risks of colonoscopy (sedation, bowel prep, bleeding/perforation) outweigh potential benefits
- Your age and number of prior normal colonoscopies indicate a low risk of developing colon cancer
The decision about when to stop colonoscopy screening should involve a thorough discussion with your physician about your personal health status, colonoscopy history, and pros/cons of continuing screening.
What Medicare Will Cover After Routine Screenings Stop
After it is determined routine colonoscopy screenings should be discontinued, Medicare will still cover:
- Diagnostic colonoscopies – if you have symptoms or there are signs of gastrointestinal issues on other tests, Medicare covers colonoscopy for diagnosis and treatment.
- Surveillance colonoscopies – Medicare still covers colonoscopies recommended by your physician after cancer treatment or if polyps were previously found.
- Screening fecal tests – Medicare covers the fecal immunochemical test (FIT) every 12 months for colorectal cancer screening.
So while Medicare may stop covering preventive screening colonoscopies after a certain age, the program will still pay for colonoscopy and other tests that are medically necessary for evaluating symptoms, monitoring after treatment, or ongoing surveillance screening.
Paying for Colonoscopy When Medicare Won’t Cover
If Medicare denies coverage because your screening colonoscopy does not meet the guidelines, you have a few options to pay for the procedure:
Medicare Supplemental Insurance (Medigap)
Most Medigap plans cover your coinsurance or copayments for Medicare-approved procedures. Some may fully or partially cover non-approved preventive services like a colonoscopy not covered by Medicare. Contact your plan to see if the colonoscopy will be paid for.
Medicare Advantage Plan
Medicare Advantage plans sometimes offer additional preventive benefits beyond what Original Medicare covers. See if the colonoscopy screening falls under the plan’s expanded wellness benefits.
Pay Out-of-Pocket
You can choose to pay for the full colonoscopy cost yourself if Medicare denies coverage. Costs average around $1,500 but can range from $800 – $3,000 depending on if you need sedation and biopsy. Ask your doctor for an estimate beforehand so you can budget properly.
Switch to High Deductible Plan
You may want to temporarily switch to a lower premium High Deductible Medicare Advantage Plan during the year you plan to get the colonoscopy. Preventive services are typically covered by these plans before you meet the deductible.
Health Savings Account (HSA)
If enrolled in a High Deductible Health Plan, you can pay for the colonoscopy using a Health Savings Account (HSA). HSAs let you set aside pre-tax money that rolls over yearly and can be used for qualified medical expenses.
Does Medicare Cover Colonoscopy Under Part B or Part D?
Medicare Part B covers medically necessary colonoscopies and related services. This includes:
- The procedure cost
- Physician services
- Sedation/anesthesia
- Removal of polyps
- Biopsies and pathology
- Facility fees
Colonoscopy medications like bowel prep kits or prescriptions for sedation will be covered under Medicare Part D. But keep in mind that Medicare drug plans cannot cover medications self-administered in the hospital outpatient setting.
If your colonoscopy with biopsy or polyp removal is performed as an outpatient at a hospital, the bowel prep kits and sedation meds given while you are there may not be covered under Part D. Talk to your plan about coverage beforehand.
Conclusion
In summary, Medicare generally provides coverage for routine screening colonoscopies every 10 years starting at age 50. Higher risk individuals can qualify for colon cancer surveillance every 2 years.
While there is no defined age limit, colonoscopy screening is not recommended on a routine basis after age 75-85 in average risk people. However, Medicare will still cover colonoscopies that are diagnostic or medically necessary after screening stops.
If Medicare denies a preventive colonoscopy due to not meeting timeframe guidelines, there are ways you may be able to cover the costs through supplemental insurance, Medicare Advantage benefits, or paying out-of-pocket. Understanding Medicare’s colonoscopy coverage rules can help you plan for routine colorectal cancer screening.
