There are two types of colonoscopies:
1. Diagnostic (also known as medical)
2. Screening (also known as preventative or routine) (Screenings are also classified as average or high risk)
A diagnostic colonoscopy is performed for a patient with symptoms. (Examples: constipation, diarrhea, weight loss, abdominal pain, rectal bleeding, anemia, history of colon polyps or cancer)
Average risk screening – A patient that is at least 50 years old and has no past or current bowel symptoms and no risk factors.
High risk or surveillance screening – A patient with risk factors or personal history of colon polyps and/or colon cancer, a family history of colon polyps and/or colon cancer and certain inflammatory bowel diseases. The age of the patient would not apply. Due to your risk factor, your physician will recommend you have these more frequently.
How does my insurance cover my colonoscopy?
A diagnostic or medical colonoscopy is generally subject to one’s major medical benefits, deductibles, co-insurance and/or co-pays). These are performed as an outpatient procedure so checking your benefits for “outpatient surgery” will give you a better idea of what type of out-of-pocket expenses you may incur.
An average risk screening is generally covered by one’s wellness benefits. Most (not all) insurance companies will cover this at 100%, once every ten years and the patient must be over the age of 50. However, if during your screening colonoscopy a diagnosis is made, an additional procedure is performed and/or biopsy or specimen is collected, you may be responsible for out of-pocket costs as a “diagnostic/medical colonoscopy”.
A high risk or surveillance screening coverage is specific to your insurance company. Some insurance companies will cover these under wellness benefits and some will cover these under major medical benefits. Insurance companies DO NOT have to cover these at 100%.
**This is only a general guideline of insurance coverage for your colonoscopy benefits. Each insurance company will vary their coverage and costs.