Does Aetna Medicare Cover Colonoscopy Screenings?

If you’re over 45, your doctor may recommend a colonoscopy to screen for early signs of colorectal cancer and other conditions of the large intestine. Aetna Medicare Advantage (Medicare Part C) plans, which provide healthcare benefits to beneficiaries, cover the cost of screening colonoscopies for all plan participants. However, rules may differ if the procedure is recommended for diagnostic or treatment purposes.

Before you schedule this common test, read below for some things you should know about how and when an Aetna Medicare Advantage plan covers colonoscopies. 

Does Aetna Medicare Cover a Colonoscopy for Colorectal Cancer Screening?

Under federal guidelines, Aetna Medicare Advantage plans are required to provide the same minimum benefits as Original Medicare Parts A and B. That includes coverage for 100% of the cost of a screening colonoscopy every 10 years for any beneficiary with an average risk profile and every 2 years for individuals at higher risk for developing colorectal cancer, including those with a family history of the disease.

More frequent screenings may be approved for individuals whose initial screenings returned abnormal or inconclusive results.

Does Aetna Medicare Cover a Colonoscopy for Diagnostic and Treatment Purposes?

Aetna Medicare Advantage plans may also cover a colonoscopy if it’s necessary for diagnostic or treatment purposes. Depending on the individual policy, beneficiaries may be required to receive services through a plan-approved physician at a participating facility.

Is There a Copay for a Colonoscopy With Medicare?

If a colonoscopy is performed for screening purposes, there’s typically no cost to a Medicare beneficiary, whether they have Original Medicare or a Medicare Advantage plan (if the services are received from a provider in the plan network).

However, if a colonoscopy is performed for diagnostic or treatment purposes, the beneficiary may be responsible for a copayment or coinsurance, depending on the terms of their policy and where the colonoscopy was performed.

Because Medicare Advantage plans are legally required to provide the same minimum benefits as Original Medicare, Aetna Medicare Advantage plan participants shouldn’t have to pay more than 20% of the cost of a qualified screening colonoscopy when performed by an in-network provider and if any applicable deductible has been met. However, Aetna policies vary, and some plans may provide higher coverage.

Plan participants can find out coverage details for their Aetna policy by contacting Aetna directly.

When Do Physicians Recommend Colonoscopies?

Colonoscopies are commonly performed for one of three reasons: screening, diagnosis or treatment of an illness.

Screening for Colorectal Cancer

A colonoscopy is a common screening tool that’s used to detect early signs of colorectal cancer and other conditions by giving healthcare practitioners a magnified view of the large intestine.

The U.S. Preventive Services Task Force recommends colorectal cancer screenings for individuals aged 45 through 75 who are at average risk for the disease, although testing may be performed earlier for individuals who have experienced symptoms associated with colorectal cancer or who have a family history of the disease.

Although the risk of complications increases with age, screening colonoscopies may be selectively recommended for individuals between the ages of 76 and 85.

Diagnosis of a Medical Condition

Physicians may also recommend a colonoscopy to aid in the diagnosis of an individual experiencing any of the following symptoms:

• Abdominal pain
• Rectal bleeding
• Low iron level
• Reduced blood count
• Unexplained weight loss
• Changes in bowel habits

Treatment of a Medical Condition

A colonoscopy may also be performed in the treatment of an illness or medical condition. Common reasons to perform a colonoscopy include removal of a polyp or foreign body and placement of a stent to increase the diameter of the intestine, so fluids and stool can pass through more easily.

What Can You Expect Before, During and After a Colonoscopy?

Before undergoing a colonoscopy, you’ll complete a bowel cleanse, which involves prescription laxatives that help empty the intestines for clearer imaging. Then, on the day of the procedure, your healthcare provider will direct you to lie on a table, often on your left side.

After administering anesthesia, pain medication or a sedative, they’ll insert a narrow scope through your anus and into your rectum and colon.

During the procedure, the scope releases air or water to inflate the large intestine, and real-time video is transmitted to an in-room monitor, letting your provider visually inspect the walls of your intestine. You may be asked to adjust your position periodically to give your physician a better view. If they see polyps or abnormal tissue, they can immediately remove a sample for further testing.

After the visual inspection is done, the doctor slowly removes the colonoscope, completing the exam. The entire procedure typically takes between 30 and 60 minutes.

Although a colonoscopy isn’t usually painful, some individuals have stomach cramping or an urge to have a bowel movement. Afterward, you may experience bloating or gas, but the procedure has few risks of complications overall.

Does Medicare Stop Covering Colonoscopies After a Certain Age?

Although some physicians recommend alternative colorectal cancer screening tools for individuals past the age of 75, Medicare covers colonoscopies for beneficiaries of any age. 

Are There Other Ways to Screen for Colorectal Cancer?

There are several alternative ways to effectively screen for colorectal cancer, including:

• Sigmoidoscopy: Although a sigmoidoscopy also uses a scope to examine the intestinal wall, it only looks at the lower part of the large intestine. The procedure may be used to perform diagnostic testing on the colon or remove abnormal tissue for testing.
• Virtual colonoscopy: Also known as a CT colonography, this test uses a CT scanner to get detailed images of the large intestine.
• Stool DNA testing: Self-administered tests, such as Cologuard, screen an individual’s stool sample for blood and the presence of DNA that may indicate colon cancer.
• Fecal immunochemical testing: FIT is a self-administered test that detects trace amounts of blood in the stool using antibodies.
• Fecal occult blood testing: FOBT analyzes a stool sample for blood that may indicate the presence of polyps or colon cancer.

Some of these tests may return false positives or negatives, and a follow-up colonoscopy may be recommended if a screening returns abnormal results.

Does Aetna Medicare Cover Alternative Colorectal Screening Tests?

Part C plans, such as Aetna Medicare, cover some alternative colorectal screening methods, including Cologuard and other blood-based biomarker screening tests. However, beneficiaries typically need a doctor's referral, and they may also need to meet plan-specific age or medical criteria. Aetna Medicare Advantage plans may also differ widely by region and policy type.

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