Medicare covers most endoscopies when your doctor orders one to diagnose or treat a medical problem

Medicare Part B covers the cost of an endoscopy if your doctor considers it medically necessary. This means the procedure must be ordered to find out what is causing your symptoms or to treat a condition your doctor has already identified. Medicare will pay 80 percent of the approved amount after you meet your Part B deductible for the year. You pay the remaining 20 percent, unless you have a Medigap or Medicare Advantage plan that covers additional costs.

The type of endoscopy matters. A screening endoscopy — one done to look for disease when you have no symptoms — is covered differently than a diagnostic endoscopy, which is done because you have symptoms or a known condition. Medicare covers screening colonoscopies at no cost to you every 10 years if you are 50 or older and have never had one, or every 2 years if you are at high risk. Other screening endoscopies, like those for Barrett's esophagus, may have different coverage rules.

Key Takeaways

  • Medicare Part B covers endoscopies ordered by your doctor as medically necessary, and you pay 20 percent of the approved amount after your deductible.
  • Screening colonoscopies for people 50 and older are covered at no cost to you, but other screening endoscopies may require you to pay a share.
  • The facility where the endoscopy is performed — hospital, outpatient surgery center, or doctor's office — affects what you pay.
  • If a polyp is removed or a biopsy is taken during the endoscopy, the procedure may be classified as therapeutic rather than screening, which changes your cost.
  • Your doctor's office should tell you before the procedure whether Medicare will cover it and what your out-of-pocket cost will be.

How Medicare decides what to cover

Medicare uses specific medical codes to decide whether an endoscopy is covered and how much it will pay. Your doctor assigns a code based on what the endoscopy is for — looking for bleeding, checking for ulcers, removing a polyp, or taking a tissue sample. The code determines whether Medicare sees the procedure as screening, diagnostic, or therapeutic.

If your endoscopy starts as screening but your doctor finds and removes a polyp or takes a biopsy, Medicare may reclassify it as therapeutic. This can change your cost-sharing. For example, a screening colonoscopy costs you nothing, but if a polyp is removed during that same procedure, you may owe 20 percent of the approved amount for the removal portion. Your doctor's office should explain this possibility before the procedure.

What you pay depends on where the procedure happens

An endoscopy can be done in a hospital outpatient department, an ambulatory surgery center, or a doctor's office. Medicare pays differently depending on the setting, and your cost-sharing changes accordingly.

In a hospital outpatient department, you typically pay a copay (a set amount like $250 to $500) plus 20 percent of any additional charges after your deductible. In an ambulatory surgery center or doctor's office, you usually pay 20 percent of the approved amount after your deductible, with no separate copay. Ask your doctor's office which setting they use and what your out-of-pocket cost will be before you schedule.

Screening colonoscopies have special coverage rules

Medicare covers a screening colonoscopy at no cost to you if you are 50 or older and have no symptoms. You must have had no colonoscopy in the past 10 years, or no sigmoidoscopy in the past 5 years, or no barium enema in the past 5 years. If you are at high risk for colorectal cancer — because of family history, inflammatory bowel disease, or a genetic syndrome — Medicare covers screening colonoscopies every 2 years at no cost.

If you are under 50 and your doctor orders a colonoscopy because you have symptoms like bleeding or chronic diarrhea, Medicare covers it as a diagnostic procedure, not a screening. You will pay 20 percent of the approved amount after your deductible.

Other types of endoscopies and their coverage

Endoscopies of the stomach, small intestine, and esophagus are covered when medically necessary. An upper endoscopy (esophagogastroduodenoscopy or EGD) is covered if you have symptoms like difficulty swallowing, persistent heartburn, or upper abdominal pain. An endoscopic ultrasound is covered to evaluate pancreatic or bile duct problems. A capsule endoscopy, where you swallow a small camera to look at your small intestine, is covered if other tests have not found the cause of bleeding or chronic diarrhea.

Medicare covers these procedures at 80 percent of the approved amount after your deductible. The specific reason your doctor orders the endoscopy must be documented in your medical record, because Medicare reviewers may ask for that documentation later.

What to do before scheduling an endoscopy

Before you schedule, ask your doctor whether Medicare will cover the procedure and what your out-of-pocket cost will be. Your doctor's office can contact Medicare or check the Medicare website to find the approved amount for the specific procedure code they plan to use. This tells you what 20 percent will cost you.

If you have a Medicare Advantage plan instead of Original Medicare, your coverage and costs may be different. Call your plan's customer service number to ask whether the endoscopy is covered and what you will owe. If you have a Medigap policy, it may cover some or all of your 20 percent cost-sharing, depending on which policy you have.

Ask whether the facility will bill Medicare directly or whether you will need to pay upfront and request reimbursement. Most facilities bill Medicare directly, but some smaller offices may not. If you will be paying out of pocket, ask whether the facility offers a payment plan.

When Medicare may deny coverage

Medicare may not cover an endoscopy if your doctor cannot show it was medically necessary. For example, if you request an upper endoscopy for general screening with no symptoms and no medical reason, Medicare will likely deny it. If you have had a colonoscopy within the past 10 years and request another one without symptoms or a medical reason, Medicare may deny the second one.

If Medicare denies coverage, you have the right to appeal. Your doctor's office can submit additional medical records explaining why the procedure was necessary. If you disagree with the denial, you can file a formal appeal with Medicare. The process takes time, so ask your doctor's office to help you understand whether an appeal is likely to succeed.

Frequently Asked Questions

Will I have to pay anything for a screening colonoscopy?

No. If you are 50 or older with no symptoms and have not had a colonoscopy in the past 10 years, Medicare covers the entire cost. If a polyp is found and removed during the same procedure, you may owe 20 percent of the approved amount for the removal, but the screening portion itself is free.

What if my doctor finds something during the endoscopy and needs to do a biopsy?

If a biopsy is taken, the procedure is classified as therapeutic rather than screening. You will owe 20 percent of the approved amount after your deductible. Your doctor should tell you this is a possibility before the procedure so you understand your cost.

Does my Medicare Advantage plan cover endoscopies the same way?

No. Medicare Advantage plans set their own coverage rules and cost-sharing amounts. Call your plan's customer service number before scheduling to find out what you will owe. Some plans cover screening colonoscopies at no cost, while others may charge a copay.

What happens if Medicare denies my endoscopy?

You have the right to appeal. Ask your doctor's office to submit medical records showing why the procedure was necessary. If you disagree with the appeal decision, you can request a hearing. The process takes several weeks, so ask your doctor whether an appeal is worth pursuing in your situation.

Can I get a second opinion before having an endoscopy?

Yes. If you are unsure whether you need an endoscopy, you can ask another doctor for their opinion. Medicare covers the cost of a consultation with another doctor. Getting a second opinion does not delay coverage — if both doctors agree the procedure is necessary, Medicare will cover it.