Does Anthem Medicare Cover a Colonoscopy and Related Costs?

A colonoscopy is a common medical procedure used to screen older adults for cancer, polyps and other changes in the large intestine and rectum.

Like all Medicare Advantage (Medicare Part C) plans, Anthem Medicare covers colonoscopy screenings for participants who have reached the recommended age or who meet other relevant criteria to qualify for Medicare colonoscopy coverage. Medicare Advantage plans like the ones offered by Anthem are required to cover everything covered by Original Medicare (Medicare Parts A and B).

If your doctor has recommended a colonoscopy for screening or other purposes, here’s what you should know about this procedure and its coverage guidelines under a Medicare Advantage plan from Anthem or one of their affiliated companies such as Blue Cross and Blue Shield.

Who Should Have a Colonoscopy?

Although other tests are now available, colonoscopy remains one of the most popular tools for the early detection of colorectal cancer.

The U.S. Preventive Services Task Force recommends screenings beginning at age 45 for individuals who are at average risk for the disease, haven’t exhibited any symptoms and don’t have a family history of related cancers. Once an individual passes the age of 75, the task force recommends selective screenings for individuals through age 85.

A colonoscopy may also be recommended to help diagnose individuals who are experiencing one or more of the following symptoms:

• Abdominal pain
• Chronic diarrhea
• Rectal bleeding
• Low iron levels
• Low blood count
• Unexplained weight loss
  

A physician may also recommend a colonoscopy to place a stent or remove a foreign body from the large intestine.

How Is a Colonoscopy Performed?

A colonoscopy, which is typically done on an outpatient basis, is performed by inserting a scope through your anus into your rectum and colon. During the procedure, you’ll lie on a table and receive intravenous sedatives, pain medication or anesthesia, depending on your doctor’s recommendations and your preferences.

Once inserted, the scope inflates your large intestine with air and sends real-time images to a monitor, letting your physician perform a thorough visual inspection of your intestinal tract. You may be asked to adjust your position during the procedure to give your physician a better view. If polyps or abnormal tissue are found, they may be removed using the colonoscope and sent for a biopsy.

When the imaging is complete, your doctor removes the scope, and the procedure is over. The entire test typically takes about 30 to 60 minutes. 

When Will Anthem Medicare Pay for Colonoscopy?

Anthem Medicare Advantage plans covers qualified screening colonoscopies for plan members.

Although plan specifics may vary depending on the individual policy, Medicare minimum coverage guidelines require Anthem to pay for a screening colonoscopy every 10 years for beneficiaries with an average risk of developing colorectal cancer. For individuals who are at high risk for the disease or who were screened and had abnormal test results, a colonoscopy may be covered once every 2 years.

Anthem Medicare Advantage plans may also cover a colonoscopy for individuals who need to undergo the procedure for diagnostic or treatment purposes. However, the procedure must be deemed medically necessary by a plan-approved physician, and participants may be required to visit an in-network practitioner for the test.

Is There a Copay for a Colonoscopy With Medicare?

There’s typically no cost to a Medicare beneficiary for a colonoscopy used for screening purposes. However, an individual undergoing a colonoscopy for diagnostic or treatment purposes may be responsible for a copayment and coinsurance, and may need to meet any applicable deductible before the plan pays for the procedure. 

Original Medicare Part B typically covers 80% of a colonoscopy used for diagnostic or treatment purposes. To find out what your Anthem Medicare plan covers for a diagnostic- or treatment-related colonoscopy, contact your Anthem Medicare Advantage plan administrator or other Anthem representative. 

Does Anthem Cover Anesthesia and Facility Charges for a Colonoscopy?

Anesthesia used during a colonoscopy is covered under the same plan guidelines as the procedure itself.

• If the colonoscopy is for preventive screening purposes, Anthem typically helps cover the anesthesia and other facility charges.
  
  
• If the colonoscopy is for diagnostic or treatment purposes, a copay or co-insurance may apply and any applicable deductible must be met before the plan pays for these services.

Does Anthem Medicare Cover Colonoscopy Prep Materials?

When prescribed by a doctor, the bowel preparation materials required for a colonoscopy may be covered under an Anthem Medicare Advantage plan that includes prescription drug coverage. To find out if your policy covers this kit, contact your plan administrator or an Anthem representative. 

At What Age Does Medicare No Longer Cover a Colonoscopy?

Although less invasive procedures may be recommended to screen for colorectal cancer in individuals over the age of 75, Medicare covers colonoscopies at any age. 

Are There Alternatives to a Colonoscopy?

Depending on an individual’s risk profile and preferences, the following screening tools may also be used to screen for colorectal cancer:

• Although a sigmoidoscopy is similar to a colonoscopy, it’s slightly less invasive because the scope is only inserted into the lower part of the large intestine. A sigmoidoscopy may also be used to biopsy tissue or perform diagnostic testing on the colon.
  
  
• Fecal immunochemical testing: FIT is a DIY at-home test that uses antibodies to screen for trace amounts of blood in an individual's stool. Screening is typically done every 1 to 2 years.
  
  
• Fecal occult blood testing: FOBT screens an individual's stool sample for blood that isn’t visible to the naked eye. Screening is typically done every 2 years.
  
  
• Stool DNA testing: This test screens an individual's stool sample for blood and DNA that may indicate colon cancer. It may be used in conjunction with fecal immunochemical testing.
  
  
• CT colonography: During CT colonography, a technician inflates the colon with air and takes detailed images that can reveal any abnormalities present.

If any of these screening tests return abnormal or inconclusive results, a colonoscopy or other testing may also be required to rule out colorectal cancer or make an accurate diagnosis.

Does Anthem Medicare Cover Alternative Screening Methods?

Anthem Medicare plans cover some alternative screening methods, such as fecal occult blood tests and blood-based biomarker testing, with a doctor’s referral. However, beneficiaries may need to meet certain medical or age criteria before coverage is approved. 

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