Medicare covers most endoscopy procedures when your doctor orders them for diagnosis or treatment of a medical condition

Medicare Part B covers endoscopy as a diagnostic or therapeutic procedure, meaning it pays for the procedure itself when performed in a hospital, outpatient surgery center, or doctor's office. You pay 20% of the Medicare-approved amount after you meet your Part B deductible for the year. The exact cost depends on the type of endoscopy, where it is performed, and whether the doctor finds and removes something during the procedure — like a polyp or tissue sample.

The key requirement is that your doctor must order the endoscopy for a medical reason. Medicare does not cover screening endoscopies (like colonoscopies) before age 50, or more frequently than Medicare's guidelines allow. If you have symptoms or a medical condition that warrants investigation, the procedure is typically covered.

Key Takeaways

  • Medicare Part B covers endoscopy when ordered by your doctor for diagnosis or treatment, and you pay 20% of the approved cost after meeting your deductible.
  • Screening colonoscopies are covered once every 10 years starting at age 50, or more often if you have risk factors or a personal history of polyps.
  • If your doctor removes a polyp or takes a tissue sample during the procedure, you may owe an additional charge because the procedure code changes.
  • Medigap or Medicare Advantage plans may cover some or all of your 20% coinsurance, depending on your plan.
  • You should ask your doctor's office to verify coverage before the procedure so you know your out-of-pocket cost.

Types of Endoscopy Medicare Covers

Medicare covers several types of endoscopy. Colonoscopy — examination of the colon and rectum — is covered for screening once every 10 years starting at age 50, or more frequently if you have symptoms, a family history of colorectal cancer, or a previous finding of polyps. Upper endoscopy (esophagogastroduodenoscopy or EGD) examines the esophagus, stomach, and upper small intestine and is covered when you have symptoms like difficulty swallowing, persistent heartburn, or abdominal pain. Sigmoidoscopy examines the lower colon and is covered for screening or diagnosis.

Medicare also covers other endoscopic procedures such as bronchoscopy (examination of the airways), cystoscopy (examination of the bladder), and enteroscopy (examination of the small intestine). The coverage rule is the same: the procedure must be medically necessary, not purely preventive or elective.

What You Pay Out of Pocket

Your out-of-pocket cost depends on whether you have met your Part B deductible and whether anything is removed or biopsied during the procedure. If you have not met your deductible, you pay the full deductible amount first, then Medicare pays 80% and you pay 20% of the approved amount. The 2024 Part B deductible is $240, but this amount changes each year.

If your doctor removes a polyp, takes a tissue sample, or performs a therapeutic intervention during the endoscopy, the procedure code changes and you may owe an additional charge. For example, a screening colonoscopy with polyp removal is billed differently than a screening colonoscopy without removal. Ask your doctor's office to estimate your cost before the procedure, including any likely additional charges.

If you have a Medigap plan, it may cover your 20% coinsurance. If you have a Medicare Advantage plan, your out-of-pocket cost depends on your plan's copay or coinsurance structure — check your plan documents or call the plan to confirm.

Screening Colonoscopy Coverage Rules

Medicare covers screening colonoscopy once every 10 years for people age 50 and older with no symptoms or history of polyps. If you have a family history of colorectal cancer or a personal history of polyps, adenomas, or inflammatory bowel disease, Medicare covers colonoscopy more often — typically every 5 years or even every 2 years, depending on your risk. Your doctor determines the appropriate screening interval based on your medical history.

If you are under age 50, Medicare does not cover screening colonoscopy unless you have symptoms or a medical condition that warrants investigation. If your doctor orders a colonoscopy because you have abdominal pain, bleeding, or a change in bowel habits, it is considered diagnostic rather than screening, and Medicare covers it regardless of age.

How to Verify Coverage Before Your Procedure

Before scheduling an endoscopy, ask your doctor's office to contact Medicare or your insurance plan to verify that the procedure is covered. Provide the office with your Medicare card and any supplemental or Medicare Advantage plan information. The office should be able to tell you whether the procedure is covered and what your estimated out-of-pocket cost will be.

You can also call Medicare directly at 1-800-MEDICARE (1-800-633-4227) to ask about coverage for a specific procedure. Have your Medicare number and your doctor's information ready. If you have a Medicare Advantage plan, call the plan's customer service number on the back of your card instead, because coverage and costs vary by plan.

What Happens If the Procedure Is Not Covered

If Medicare determines that the endoscopy is not medically necessary, you may receive a notice called an Advance Beneficiary Notice (ABN) before the procedure. The ABN tells you that Medicare may not pay and gives you the choice to proceed at your own cost or cancel. If you sign the ABN and proceed, you are responsible for the full bill if Medicare denies the claim.

If you believe Medicare should cover the procedure, you can appeal the denial. Your doctor's office can help you gather medical records and documentation to support the appeal. The appeals process takes time, so discuss your options with your doctor and the billing office before making a decision.

Medicare Advantage and Medigap Coverage Differences

If you have a Medicare Advantage plan, your endoscopy coverage and out-of-pocket costs may differ from Original Medicare. Some Medicare Advantage plans cover endoscopy with a copay (for example, $150 for an outpatient procedure) rather than 20% coinsurance. Others may require prior authorization from the plan before the procedure. Check your plan's summary of benefits or call the plan to confirm what you will owe.

If you have a Medigap plan, it typically covers the 20% coinsurance that Original Medicare does not pay, so your out-of-pocket cost may be lower. However, Medigap does not cover the Part B deductible, so you still pay that amount out of pocket. Review your Medigap plan documents to confirm what is covered.

Frequently Asked Questions

Will Medicare cover my endoscopy if I have no symptoms?

Medicare covers screening colonoscopy once every 10 years starting at age 50, even without symptoms. For other types of endoscopy, Medicare covers the procedure only if you have symptoms or a medical condition that warrants investigation. If your doctor orders an endoscopy for screening purposes other than colonoscopy, ask whether Medicare will cover it before the procedure.

What if my doctor finds cancer or a large polyp during the endoscopy?

If your doctor removes a polyp or takes a tissue sample during the procedure, the procedure code changes and you may owe an additional charge beyond the screening colonoscopy cost. Medicare covers the removal or biopsy as part of the medically necessary procedure. Ask your doctor's office about the additional cost before the procedure if possible.

Do I need prior authorization from Medicare before my endoscopy?

Original Medicare does not require prior authorization for most endoscopy procedures. However, if you have a Medicare Advantage plan, your plan may require prior authorization. Call your plan's customer service number before scheduling to confirm whether authorization is needed.

What if I have not met my Part B deductible yet this year?

You pay the full Part B deductible amount first, then Medicare pays 80% and you pay 20% of the approved amount for the endoscopy. The deductible applies only once per calendar year, so once you meet it, you pay only the 20% coinsurance for any other Part B services for the rest of the year.

Can I get a refund if I paid out of pocket for an endoscopy before I had Medicare?

No, Medicare does not cover procedures performed before your coverage began. If you paid out of pocket for an endoscopy before enrolling in Medicare, you cannot file a claim for reimbursement. This is why it is important to enroll in Medicare as soon as you are may be able to access.