COLONOSCOPY UNDER AGE 50 ~ INSURANCE WON'T PAY - Page 4

hckynut · ‎03-10-2010

Medicare has paid for all 15 of my Colonoscopy's and 5 Double Balloon Enteroscopies, which included "followup procedures" when I was not currently bleeding. They also paid for my Endoscopy''s, which is at least 15 of them, 1 of which was an Upper Double Balloon Endoscopy.

Might want to check the Code your Gastro Doctor is using.

hckynut(john)

NYC Susan · ‎03-13-2010

@Love my grandkids wrote:
@teainlondon Wow I never heard that about being 70. I'm almost 70 and 1/2. I have Medicare and United Healthcare as a supplemental and have had no problems with getting everything covered.

I do have small co-pays for my meds, but that's it.

Last year I had a colonoscopy, surgery for colon cancer (all is well), chemo, radiation, MRI, scans, a port put in, blood transfusions (was anemic) and iron infusions.

ALL of it was covered. Just had a colonoscopy and it was covered and I'm over 70.

I've never heard of this either. I'm involved in the medical bills for relatives in their 80's and 90's. They all have Medicare. One has Advantage, and the others have Supplemental Plans. There have been no problems with coverage ever.

tends2dogs · ‎05-08-2010

@conlt wrote:
I had my first colonscopy at 43 17 years ago. Back then nothing was covered under wellness, but because my physician thought that I might have an abdominal mass, the procedure was covered after my deducible and copay. I was fine, not problems, I had my 2nd one at 50, no problems and am planning my third now that I am 60. I will go in as wellness but if they find anything, it becomes a medical procedure and goes under the copay and deductible. I would have him talk to the billing department there. They should know how to code his condition, but it sounds to me because he is having pain, the colonoscopy will not be covered under wellness. I had a friend who was diagnosed at age 49 with stage 4 colon cancer and she died 9 months later. It was awful. The begged people to get their colonoscopy's done.

@conlt and all others who responded. Apparently it is being billed under wellness even though there are symptoms. He has a large copay and deductible that hasn't been met so he will be responsible for the full amount. His HR dept has given numbers to call to help with this because apparently after the age of 50, the full amount would be covered under wellness. I am getting all this second hand. He knows he needs it done and will get it done, but wants to get the financial part straightened out first. DH told him to go back to the doctor and have them recode it. Time will tell if he does. They live a state away and we don't see them often. DH talks to him all the time. This was the first mention of health problems by him. Now that DH knows about this, he will stay on him to carry through with it.

As a side note, DS's wife had breast cancer a couple years ago. She did 6 months of chemo and had a double mastectomy. She is doing well, but there has been a lot of stress the last couple years. It is time for him to take care of himself.

Fear not Brothers and Sisters! I have read THE BOOK..........we win!!!

chrystaltree · ‎05-10-2010

They won't cover a routine colonoscopy but they most certainly do cover colonoscopies if the patient has symptoms. Good grief even babies have colonoscopies. If he has rectal pain, abdominal pain, rectal bleeding or constipation; insurers will cover a colonoscopy. The problem might be that the doctor's office did not use the correct diagnosis codes when they asked for insurance authorization.

Lipstickdiva · ‎03-10-2010

@Carmie wrote:
@Nightowlz wrote:
I think this is a bunch of BS. The Ins Co should cover it. They won't pay when it's diagnostic.
Same thing happened to my girlfriend when she went in for a lump in her breast. Since she mentioned it Ins would not pay for it as they said it was a daignosis. She should have just went in for her yearly & not said anything until after her mammogram. You can bet your sweet ****** I won't every say anything when I see the doctor.
I have talked to my gyn doctor about it before. I ask are you recording this if so turn it off. I say I don't really know what I can say when I see you & what I can say in fear of saying something & now Ins won't cover my bill. He fully understood where I was coming from.
Insurance companies all pay for diagnostic services..they are required to by law.

Diagnostic services are subject to your deductible, coinsurance and copayments if you have them and routine services are not.

Your friend probably has a high deductible and the cost of her services would be applied to that deductible, so she would have to pay out of her pocket for that mammogram. It is a covered diagnostic service, just subject to the terms of her insurance policy.

it is not correct to say that insurance doesn't for diagnostic services.

Exactly. The issue is, how much does the insured have to pay when it's a diagnostic test rather than a screening test?

For example, a screening/preventive colonoscopy is covered by my insurance as part of my wellness exam. However, if something were to show up that needed biopsied, that changes the procedure to a diagnostic colonoscopy and then I have to pay a portion and it's applied to my deductible. It's not that my insurance won't pay.

Lipstickdiva · ‎03-10-2010

As an aside, the American Cancer Society has changed the recommendation from 50 to 45.

CelticCrafter · ‎03-09-2010

Even though they should know the age guidelines, maybe they thought they were doing him a favor, cost wise, by coding it as preventative?

AuntMame · ‎10-16-2010

@Lipstickdiva

Exactly. The issue is, how much does the insured have to pay when it's a diagnostic test rather than a screening test?

For example, a screening/preventive colonoscopy is covered by my insurance as part of my wellness exam. However, if something were to show up that needed biopsied, that changes the procedure to a diagnostic colonoscopy and then I have to pay a portion and it's applied to my deductible. It's not that my insurance won't pay.

This.

It may not matter how the procedure is coded. If the colonoscopy is diagnostic, i.e., it's being done because there are symptoms, as opposed to wellness/screening, the patient may be required to pay co-pays and deductibles.

The doctor's office can code it as wellness/screening but if the insurance co's rules for screening aren't met--for instance the patient is not 50 or older, the insurance co may still consider it diagnostic and only pay (or not) accordingly. Sucks doesn't it?

I've fought this battle. Particularly with mammograms. If I go into a screening mammogram reporting that I've found a lump it gets coded as diagnostic and I end up paying for it even if it's technically my annual screening mammogram.

lovesrecess · ‎03-14-2010

If the dr is recommending a colonoscopy based on symptoms, there is no reason why the insurance shouldn't pay...who on earth would want to have one for no reason? A wellness check periodically is one thing...but symptoms and age 48 should not even be questioned....but as everyone knows by now...it isn't about the patient anymore...it's only about the coding!