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Does Medicare Cover Endoscopies?

When it comes to diagnosing what ails you, a doctor has many different strategies to rely on. They could make an educated guess based on symptoms or they could run tests and utilize procedures that give them a better idea of what could be wrong. One of these procedures is an endoscopy, a useful diagnostic tool that can help doctors get a better look at what’s causing your symptoms.

But, what exactly is an endoscopy? If you’re scheduled for an endoscopy and enrolled in Medicare, you may also be wondering if your plan covers the procedure. Let’s look into the answers for both questions!

What is an Endoscopy?

As mentioned, an endoscopy is a diagnostic procedure used to get a better view of your organs and the symptoms that are causing you distress. And we mean “a better view” literally. An endoscopy involves the doctor inserting a flexible tube, usually with a scope, into your body, usually the upper or lower gastrointestinal (GI) tract.

This procedure can allow your medical team to see what’s potentially causing your GI symptoms and diagnose the problem. An endoscopy for your upper GI tract is generally inserted through your mouth and down your throat. A lower GI endoscopy, sometimes called a colonoscopy, is inserted through the… back end. These techniques are minimally invasive, making long hospital stays less likely and easing recovery.

While an endoscopy is most often inserted in the GI tract, it can also be used to see in your nose and ears, as well as around your heart, colon, and certain joints. Sometimes, an endoscopy may also be used to actively treat an issue within your GI tract. By inserting the endoscope, the doctors can cauterize an open wound, remove a polyp or precancerous tissue, or implant a stent.

It’s worth mentioning that you may not always need to exhibit symptoms for your doctor to recommend an endoscopy. Sometimes, you may receive them as a routine screening, like for certain types of cancer, or as a preventive measure to catch a developing issue before it becomes a problem.

Does Medicare Cover the Procedure?

Since endoscopies are usually not invasive, they’re usually handled in an outpatient setting. This means that you’ll be leaving the health care facility that day (though you should have someone drive you). Since they’re an outpatient procedure, Medicare Part B would cover it as long as it’s medically necessary and performed by a health care provider who accepts Medicare assignment. If your procedure is covered, you’ll need to meet your Part B deductible ($226 in 2023). After that, Medicare will pay for 80 percent of the approved cost. You’ll owe the remaining 20 percent.

There is a chance you’ll receive an endoscopy as part of inpatient care during a stay at the hospital. In this case, it’ll be covered by Medicare Part A. You’ll cover all costs until you meet the Part A deductible ($1,600 in 2023). You’ll then owe nothing until you’re there for 60 days. After that, your stay will be covered by the daily coinsurance ($400 for days 61 to 90 in 2023).

If you’re considered at high risk for colorectal cancer, Medicare will also fully cover a colonoscopy once every 24 months. While this service comes at no cost to you, if they do find and remove a polyp or tissue during the procedure, you’ll owe a 15 percent coinsurance. If you’re not considered high risk, Medicare may cover a screening colonoscopy once every 120 months or 48 months after a previous flexible sigmoidoscopy (a certain type of colonoscopy).

How Much Could an Endoscopy Cost?

So, how much will this cost you? The cost of the procedure can differ from region to region and even between different health care providers. The average cost for an endoscopy in the United States is roughly $2,750 without insurance. If you have Medicare and the procedure is covered by Medicare Part B, you’ll first owe the deductible ($226 in 2023) before coverage kicks in. Once you’ve met the deductible, you’ll eventually owe $504.80 ($2,750-$226 then multiply by .2), meaning your final out-of-pocket costs will be $730.80. Of course, this final amount will differ based on the full procedure cost and if you’ve already met your deductible or not.

A Medicare Advantage (Part C) plan may offer additional coverage, but this can differ from plan to plan. A Medicare Supplement may help with the 20 percent Part B coinsurance that Original Medicare doesn’t cover, depending on the type of plan.

What Does Recovery Look Like?

In most cases, you shouldn’t need too much time to recover from an endoscopy. You may be asked to stay for observation for an hour or two before leaving the facility. Once home, you should take it easy for a little while and follow your doctor’s orders to be safe. You may experience some light bloating, gas, cramping, or a sore throat. General discomfort isn’t uncommon either. These symptoms should all go away on their own with time. If you’re feeling pain or the symptoms aren’t going away, feel free to contact your doctor to see what steps to take next.

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Endoscopies are very common and useful diagnostic, and occasionally, treatment procedures. Thankfully, if you have Medicare, they can also be pretty affordable compared to other procedures. Considering the costs, the limited invasiveness of the procedure, and how it can help you, if your doctor feels one is medically necessary, it’s worth getting.

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