Does Medicare Cover an Endoscopy?

Does Medicare Cover Endoscopy?

Diagnostic tests like endoscopies allow your doctor to examine what's going on inside your body without you having to undergo an invasive surgery.

If you're experiencing any issues in your gastrointestinal tract, your doctor may order an endoscopy to determine what's causing your pain or discomfort. It also helps rule out more serious conditions that could be causing your symptoms, like polyps, ulcers, and even cancer.

On this page, we look at when your doctor might order an endoscopy and what your Medicare coverage looks like for these tests.

What is endoscopy?

Endoscopy is a procedure used to examine a person’s digestive tract. During the procedure, your healthcare provider inserts a flexible probe with a tiny camera into your body. (Where the endoscope enters your body depends on whether your doctor orders an upper or lower endoscopy.) The camera transmits images to a screen in real-time, allowing your doctor to see what's going on inside your digestive tract without having to cut you open.

During an upper endoscopy, an endoscope is passed through the mouth and throat and into the esophagus (the tube that goes from your mouth to your stomach). During this procedure, the doctor can view the esophagus, stomach, and the upper part of the small intestine (the duodenum).

Similarly, during a lower endoscopy, the instrument is inserted into the rectum and the large intestine. The doctor views the rectum, colon, and large intestine during this procedure. This type of endoscopy is called sigmoidoscopy or colonoscopy – depending on how far up the colon is examined.

A special form of endoscopy called endoscopic retrograde cholangiopancreatography (ERCP) takes images of the pancreas and gallbladder.

Why would a doctor order an endoscopy?

A doctor might order an endoscopy if you have the following symptoms:

  • Abdominal pain
  • Blood in your stool
  • Nausea and vomiting
  • Chronic constipation or diarrhea
  • Problems swallowing
  • Weight loss that can’t be explained

Your doctor may be able to find the reason for these symptoms with an endoscopy. For example, the procedure can be used to identify ulcers and polyps. It can also screen for cancer and other serious health conditions.

But endoscopy can also be used to treat issues in your digestive system. For example, endoscopy may be used to burn a blood vessel to stop it from bleeding, to widen a narrow esophagus, or to remove a foreign object.

So, your doctor may order an endoscopy to diagnose, screen for, or treat a disease.

How do I prepare for an endoscopy?

When preparing for endoscopy, make sure that you follow your doctor’s instructions to a T.

While upper endoscopy may require preparation as little as fasting for six to eight hours before the procedure, a lower endoscopy requires that the colon is cleared of stool. This often involves a clear liquid diet and medication to clean out the bowel.

It’s also important to note that you will be sedated for most examinations with an endoscope. The sedative will make you relax and cause you to sleep through the procedure. This is the main reason you may need someone to drive you home following an endoscopy.

Does Medicare cover endoscopies?

Typically, Medicare covers an endoscopy if a doctor deems it medically necessary and your provider accepts Medicare.

Endoscopies are typically performed in an outpatient setting, which means it is generally covered by Medicare Part B. However, you may receive an endoscopy if you are a hospital inpatient. If this is the case, Medicare Part A may cover some of the costs of the procedure.

Medicare Part B (medical insurance)

Medicare Part B typically covers outpatient medical treatments and diagnostic procedures, including endoscopies.

Depending on the type of endoscopy you receive, you may be responsible for paying the Part B deductible ($226 in 2023) and 20% coinsurance.

This means that Medicare Part B covers 80% of the cost of your procedure as long as it is medically necessary and performed by a Medicare-approved doctor who accepts assignment.

However, Medicare Part B may fully cover endoscopy if used to screen for disease.

For example, Medicare Part B will cover screening colonoscopies at 100% once every 24 months if you’re at high risk for colorectal cancer. Medicare Part B also will cover flexible sigmoidoscopy once every 48 months for those with a high risk for colorectal cancer.

If you aren’t at high risk, Medicare Part B covers a screening colonoscopy once every ten years but not within 48 months of a previous flexible sigmoidoscopy.

Medicare Part B will also cover a follow-up colonoscopy if you have a positive result on a stool-based screening test.

Please note that even if Medicare covers the cost of your screening test, you may have out-of-pocket expenses if something is discovered during your screening.

For example, if your healthcare provider finds and removes a polyp or other tissue during the procedure, you pay 15% of the Medicare-approved amount for your doctor’s services. In a hospital outpatient setting, you also pay the facility a 15% coinsurance amount. The Part B deductible does not apply.

Medicare Part A (hospital insurance)

If you receive the endoscopy as a hospital inpatient, the costs related to the endoscopy are typically covered by Medicare Part A after you meet your deductible.

For those who have Original Medicare, this is where a Medicare Supplement plan can come in handy. Better known as Medigap, these insurance plans cover many of your out-of-pocket costs when you have Original Medicare – starting with your Medicare Part A coinsurance. Most Medigap plans also cover your Part B coinsurance at 100%, although two, Plan K and Plan L, cover Part B at 50% and 75%, respectively.

Medicare Part C (Medicare Advantage)

A Medicare Advantage plan covers everything that Original Medicare covers. Medicare Advantage plans may also offer extra benefits not included with Original Medicare, such as prescription drug coverage and routine dental and vision services.

Private insurance companies provide Medicare Advantage plans, which means copays may be different than the 20% coinsurance you generally owe after Medicare pays its share. Talk to your plan provider to see what your share of costs will be for an endoscopy.

You can compare Medicare plans with our Find a Plan tool. Just enter your zip code to see the costs and benefits of Medicare plans in your area. You can also call us toll-free at 888-992-0738 and one of our licensed insurance agents will answer your Medicare questions and help you find the right Medicare coverage for you.

Additional resources

DONNA FREDERICK
After retiring from a career as an executive travel counselor in 2006, Donna Frederick embarked on a second career as a licensed insurance agent. During that first year, many clients told Donna how overwhelmed they felt by Medicare, but that her assistance helped them finally understand the Medicare program. That experience inspired Donna to focus her efforts on educating her clients to ensure they fully understand their Medicare options. Today, Donna takes pride in providing outstanding customer service and going the extra mile to make sure each client knows all of their options and has a sound understanding of their Medicare plan, from costs to coverage and all points in between.

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