Insurance Coverage of Gastrointestinal Procedures
Patients always want to know about insurance coverage of gastrointestinal procedures. Most health insurance plans categorize a Colonoscopy Screening as a “Preventative Service”. Preventive Services help to detect disease early and save lives. Some free preventive services are available annually while others are offered based on age or sex.
A colonoscopy is recommended at age 50. Patients younger than 50 and considered to be at high risk for Colon Cancer, may qualify for a free Screening Colonoscopy. These patients should contact their insurance company for prior approval.
When is a Screening Colonoscopy Free?
- A Screening Colonoscopy is free of charge if you are age 50+, or considered to be at high risk for Colon Cancer at less than age 50, and covered under an insurance plan that is accepted at Digestive Care Physicians.
- The procedure is considered to be a Screening ONLY if no symptoms of Colon Cancer are detected during the procedure. This means that no Polyps or abnormal tissues are detected or removed.
When is a Colonoscopy Not Free?
- If Polyps are removed for laboratory analysis during a Screening Colonoscopy procedure, it automatically becomes a Diagnostic Colonoscopy. Also, if a patient reports symptoms such as Rectal Bleeding or Chronic Diarrhea prior to a Screening Colonoscopy, even if no Polyps are found, it may be coded as Diagnostic to determine the cause of a problem. Learn more+
- If you have had a free Screening Colonoscopy within the last 10 years and the result indicated you had Colon Polyps, you are no longer eligible for a Screening Colonoscopy. You now have a prior history of Colon Polyps so your next Colonoscopy is considered Surveillance of the Colon and possibly Diagnostic.
- Patients that do not have insurance can take advantage of our Self-Pay program for a Screening Colonoscopy. If you are under age 50, you may not be eligible for a free Screening Colonoscopy unless you are considered to be at high risk for Colon Cancer. Patients should contact their insurance company for prior approval.
What Makes a Screening Colonoscopy Become Diagnostic and Not Free?
A Diagnostic Colonoscopy occurs when sample tissue is taken to diagnose an unusual or abnormal looking growth or section of tissue during a Screening Colonoscopy. Once tissue is taken, a Screening Colonoscopy becomes Diagnostic. Any symptom such as change in bowel habits, Diarrhea, Constipation, Rectal Bleeding, anemia, etc. prior to the procedure and noted as a symptom in your medical records may also indicate that a Diagnostic Colonoscopy is needed.
- Patients that have a family history of Polyps or Colon Cancer may require Surveillance of the Colon with continuous observation or testing. Surveillance of the Colon is considered Preventive ONLY if the patient is being observed because of risk factors (e.g., work environment) or due to family history.
- Surveillance of the Colon is considered Medical if it is being done to observe or monitor a known symptom or problem.
- If you have had a Screening Colonoscopy within the last 10 years and the result indicated you had Colon Polyps, you are not eligible for a Screening Colonoscopy. You now have a prior history of Colon Polyps so your next Colonoscopy is now considered Surveillance of the Colon and possibly Diagnostic.
Bottom line: check with your insurance carrier about insurance coverage for gastrointestinal procedures
Board-Certified physicians Dr. Ranvir Singh, Dr. Stephen Rashbaum, Dr. Nitin J. Parikh, Dr. Long B. Nguyen, Dr. Ruth Montalvo, and providers Tammi D’Elena, PA-C and Vanessa T. Bridgeman, MSN, APRN, FNP-BC; care for patients in the North Atlanta, GA; area including Johns Creek, GA, Cumming, GA, Lawrenceville, GA, Alpharetta, GA, and Dawsonville, GA. The in-house endoscopy suite at Digestive Care Physicians is a certified facility which has achieved the highest level of accreditation by the Association for Ambulatory Health Care (AAAHC). If you suffer from gastrointestinal problems, abdominal pain, or need a colorectal cancer screening, contact us at (770) 227-2222 to schedule an appointment.