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Is The Cologuard Test Covered By Medicare

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Types Of Colorectal Cancer Screening

Insurance Coverage of Cologuard®

Because colon cancer begins as growths called polyps, finding and removingpolyps is the best way to prevent colon cancer. There are three types of CRC screening:

  • Colonoscopy 95% of large polyps detected
  • Stool DNA 42% of large polyps detected
  • Fecal Immunochemical Test 30% of large polyps detected
  • Colonoscopy is the gold standard for finding polyps. If polyps are found during a colonoscopy, they are removed during the same single procedure. This eliminates the need for additional procedures or tests.

    If polyps are found through FIT or a Cologuard test, a colonoscopy must be performed to remove the polyps.

    Unfortunately, the majority of large polyps go undetected with FIT and Cologuard tests. When polyps arenât found and removed it increases the risk of developing colon cancer.

    Colorectal Cancer Screening In Patients With Cystic Fibrosis

    An UpToDate review on Cystic fibrosis: Overview of gastrointestinal disease states that The Cystic Fibrosis Foundation has developed Guidelines for Colorectal Cancer Screening for adults with CF. The guideline recommends colonoscopy for screening, beginning at age 40 years, or at 30 years for those who have had an organ transplant. The screening should be repeated every five years. If any adenomatous polyps are identified, the colonoscopy should be repeated in three years or less, depending on characteristics of the individual case. The guideline includes an intensive bowel preparation protocol that should be used for CF patients, because it is very difficult to achieve a satisfactory colonic lavage in these individuals.

    An UpToDate review on Colorectal cancer: Epidemiology, risk factors, and protective factors states that Patients with cystic fibrosis have an elevated risk of CRC. In a meta-analysis, the pooled standardized incidence ratio was 10.91, 95 % CI 8.42-14.11, and it was two- to five-fold higher following lung transplantation. The Cystic Fibrosis Foundation has developed guidelines for CRC screening for adults with cystic fibrosis. Although risk estimates are provided, the benefits of screening for CRC in these patients, who as a group have substantial comorbidities, are less certain.

    Column By Joel Mekler: Medicare And Colonoscopy Coverage

    How colonoscopies are billed can affect costs and insurance coverage.

    I consider myself to be a pretty well-informed health care consumer. Over the years, Ive helped many people navigate the healthcare maze.

    But even I recently experienced a gotcha moment that I will always remember.

    Last January, I went for my colonoscopy. Generally, the procedure is recommended once every five to 10 years, depending on your risk of getting colorectal cancer. My doctor suggested I be screened every five years because I had a personal history of colon polyps.

    I spoke with my doctors physician assistant a few weeks before the screening. He asked me for some preliminary information, like what medications I was taking and if I was experiencing any gastrointestinal issues. I did mention that I occasionally have constipation and some lower abdomen pain. The physician assistant said I was due for my next colonoscopy, so I scheduled the procedure the following month.

    Boy, was I in for a surprise when I received bills from the surgeon, anesthesiologist, and pathologist. In addition, I received a facility fee.

    I had expected that the procedure would be covered in full as part of my preventive benefits. My insurance company said the procedure was coded as diagnostic. Because of the way it was coded, I was now responsible for paying my deductible plus 15 percent coinsurance.


    You may be at high risk for colorectal cancer if you:

    Story continues below video

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    What Colonoscopy Costs Does Medicare Cover

    Medicare covers all costs associated with a colonoscopy screening for colorectal cancer so long as the doctor who does it accepts Medicare.

    If the doctor removes polyps or other tissue during the procedure, Medicare will pay 80 percent of the Medicare-approved cost.

    You will be responsible for the other 20 percent of costs. You will also be responsible for any copayment if the screening happens in a hospital setting. Your Medicare Part B deductible will not apply.

    Medicare does not cover a CT colonography sometimes called a virtual colonoscopy.

    Not all colonoscopies are for colon cancer screenings. Medicare may not fully cover these examinations. You should check with your doctor about the nature of your colonoscopy and with Medicare or your Medicare Advantage insurer about coverage and out-of-pocket costs.

    Colonoscopies that may not be fully covered by Medicare include:

    • Diagnosing symptoms, including diarrhea and bloating.
    • Diagnosing the reason for blood in the stool or bleeding from the rectum.
    • Monitoring or diagnosing irritable bowel disease .

    The Affordable Care Act

    Cologuard test can preclude insurance coverage for follow ...

    Regardless of the insurance you are having, the Affordable Care Act mandates the insurance providers to follow the guidelines of the U.S. Preventive Services Task Force for coverage. If the screening test has received an A or B rating by this agency, private insurance companies would cover the cost of the test without charging a co-pay.

    But, Medicare is exempted from this mandate and you may need to pay co-pays and co-insurance.

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    What Are The Screening Guidelines For Cologuard Under Medicare

    The U.S. Preventative Services Task Force guidelines for screening for colorectal cancer do NOT include the testing of stool DNA. On the other hand, several agencies and societies do review these tests.

    Agencies include the Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. All of which, suggest stool DNA tests for the detection of colorectal cancer.

    Medicaid Coverage For Colorectal Cancer Screening

    States are authorized to cover colorectal screening under their Medicaid programs. But unlike Medicare, theres no federal assurance that all state Medicaid programs must cover colorectal cancer screening in people without symptoms. Medicaid coverage for colorectal cancer screening varies by state. Some states cover fecal occult blood testing , while others cover colorectal cancer screening if a doctor determines the test is medically necessary. In some states, coverage varies according to which Medicaid managed care plan a person is enrolled in.

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    Who Needs A Colonoscopy

    The U.S. Preventive Services Task Force recommends that people at average risk of colorectal cancer should have regular colonoscopies starting at age 50. The American Cancer Society recommends people start screening at 45.

    The USPSTF concluded that colonoscopies provide a substantial benefit to people aged 50 to 75. But it found that a colonoscopy may not be as beneficial to people 76 to 85 whove had previous screenings.

    Colorectal cancer is most often diagnosed in people from 65 to 74 years old, and the average age of death from the disease is 73.

    How Much Does A Virtual Colonoscopy Cost

    Follow-Up Colonoscopy Coverage After a Positive Cologuard®

    The average out-of-pocket cost for a virtual colonoscopy is $2,400, but can range from less than $750 to more than $5,000, depending on the facility and its geographic location. While the procedure itself costs less than a conventional colonoscopy, it may be costlier due to co-insurance requirements and copays.

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    Update: Cologuard Stool Dna Screening Test

    This month, the Centers for Medicare & Medicaid Services issued its final National Coverage Decision for Cologuard, making it the first FDA-approved stool DNA test for the detection of colon cancer and precancer covered for Medicare patients throughout the country. This came after the exciting US FDA approval of Cologuard in August. You may have heard some buzz earlier this week about Cologuards availability to the public. It turns out some of these facts were incorrect. In order to eliminate any confusion around this new colon cancer screening test, were setting the record straight. Check out our updated FAQ to find out what you need to know.

    I have Medicare. Is Cologuard now covered under my insurance?

    Yes, on October 9, 2014 the Centers for Medicare & Medicaid issued a final determination and declared that Cologuard would be covered immediately for those on Medicare. Speak with your medical professional to determine if Cologuard is right for you.

    I have insurance through another provider. Is Cologuard now covered for everyone?

    No, Cologuard is not yet covered by private insurance. Exact Sciences, the maker of Cologuard, is actively working to get Cologuard approved for coverage by private insurance. We currently do not know when this will become effective.

    Even though Cologuard is not covered by private insurance, can I still reach out to my insurance provider to see if they would approve the Cologuard test for me?

    Additional Questions?

    How Medicare Covers Screening Colonoscopies

    Colonoscopy is considered the gold standard of colorectal cancer screening.2 If youre at high risk for colorectal cancer, Medicare will cover a screening colonoscopy once every 24 months. For those not at a high risk, Medicare will cover a screening once every 120 months or 48 months after a previous flexible sigmoidoscopy.

    Medicare will cover the costs of this test so long as your health care provider accepts assignment. You could face costs, such as a copayment, if a polyp or other tissue is found and removed during the procedure.

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    Colorectal Cancer: Risk Factors

    Medicare pays for more frequent colonoscopies for people at high risk of developing colorectal cancer.

    According to the Centers for Medicare & Medicaid Services, that means someone meets one or more of these criteria.

    • Has a personal history of colorectal cancer adenomatous polyps, a form of polyp that is benign but can become cancerous or an inflammatory bowel disease such as Crohns disease and ulcerative colitis.
    • Has a close relative a parent, sibling or child who has had colorectal cancer or an adenomatous polyp.
    • Has a family history of inherited syndromes linked to colorectal cancer, such as familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer, also known as Lynch syndrome.

    Editor’s note: This article was originally published on July 17, 2015. It has been updated with the latest information regarding Medicare coverage in 2020.

    What Are The Different Types Of Colorectal Cancer Screenings And Eligibility Requirements For Each

    Exact Sciences Announces Aetna Medicare Advantage to Cover ...

    The following are Medicare-covered colorectal cancer screening exams :

    • A fecal occult blood test is a lab test used to check stool samples for hidden blood. Original Medicare covers this test every twelve months if you are age 50 and older.
    • A screening colonoscopy is covered by Original Medicare as often as every 24 months for those at very at high risk, or once every 10 years if you are not at high risk. There is no minimum age requirement if medically-indicated by risk.
    • Cologuard is the brand name of a test that you might have seen on television. It is less invasive than colonoscopy, and is an alternative that your physician might recommend if you are at low risk for colon cancer. If so, it is a Medicare-covered test.
    • A flexible sigmoidoscopy is similar to a colonoscopy, but is much less widely recommended because it does not probe your entire colon. If ordered by your physician for a specific accepted indication, will be covered by Medicare.
    • A barium enema is an X-ray of the colon after it has been filled with barium. It is generally not used for screening. However, if ordered by your physician for a specific accepted indication, will be covered by Medicare.

    Medicare Advantage plans cover these same colorectal cancer screenings without applying deductibles, copayments or coinsurance as long as you see an in-network provider and meet Medicares eligibility requirements for these services.

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    Tests That Primarily Detect Cancer

    • Annual fecal immunochemical test with high test sensitivity for cancer or
    • Annual guaiac-based fecal occult blood test with high sensitivity for cancer or
    • Stool DNA test with high sensitivity for cancer, interval uncertain.
  • are healthy enough to undergo treatment if colorectal cancer is detected and
  • do not have comorbid conditions that would significantly limit their life expectancy.
  • The USPSTF found convincing evidence that screening for colorectal cancer in adults aged 50 to 75 years reduces colorectal cancer mortality. The USPSTF found no head-to-head studies demonstrating that any of the screening strategies it considered are more effective than others, although the tests have varying levels of evidence supporting their effectiveness, as well as different strengths and limitations:

    • Colonoscopy every 10 years
    • CT colonography every 5 years
    • Flexible sigmoidoscopy every 5 years
    • Flexible sigmoidoscopy every 10 years plus fecal immuohistochemical test every year
    • Guiaic-based fecal occult blood test every year
    • FIT test every year
    • Stool DNA every one or three years.
  • unlike guaiac tests, a fecal smear is not required for immunochemical tests — samples may be obtained from a brush sample of toilet bowl water
  • unlike guaiac tests, immunochemical tests are not affected by diet or medications, so that dietary and medicinal restrictions are not necessary prior to testing.
  • clinicians discourage individuals older than 85 years from continuing CRC screening.
  • Analysis Of Fecal Volatile Organic Compounds

    Aetna considers analysis of fecal volatile organic compounds experimental and investigational for colorectal cancer screening because the effectiveness of this approach has not been established.

    Note: The USPSTF guidelines apply to routine screening. The USPSTF guidelines have no A or B recommendations for high-risk screening. The USPSTF guidelines explain: This recommendation applies to asymptomatic adults 50 years and older who are at average risk of colorectal cancer and who do not have a family history of known genetic disorders that predispose them to a high lifetime risk of colorectal cancer , a personal history of inflammatory bowel disease, a previous adenomatous polyp, or previous colorectal cancer. When screening results in the diagnosis of colorectal adenomas or cancer, patients are followed up with a surveillance regimen, and recommendations for screening no longer apply. The USPSTF did not review or consider the evidence on the effectiveness of any particular surveillance regimen after diagnosis and removal of adenomatous polyps or colorectal cancer” .

    See also CPB 0140 – Genetic Testing, CPB 0352 – Tumor Markers, CPB 0535 – Virtual Gastrointestinal Endoscopy, and CPB 0783 – In Vivo Analysis of Colorectal Polyps and Crohn’s Disease.

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    Does Medicare Cover Cologuard

    A colonoscopy is a medical procedure in which a physician uses a scope to examine the inside of your rectum and colon. This examination can identify any ulcers, swollen tissues, polyps, or cancerous tissues that may be present. These procedures are quite invasive and require the patient to be sedated and placed under anesthesia. Cologuard provides an alternative option that allows for the detection of colorectal cancer, and Medicare benefits may include coverage for this product.

    What is Colorectal Cancer?Colorectal cancer is one of the main conditions physicians look for during colonoscopy examinations. Colorectal cancer can be found in both the colon and rectum, and these two cancers are often combined due to the similarity in symptoms.

    Cancer arises when a group of cells is not able to be regulated and is permitted to continue to duplicate, expand, and spread. This can occur in almost any area of the body, and once the growth becomes large enough, it may be transferred to other areas of the body as well.

    Colorectal cancer often arises from the formation of polyps on the inner lining of the rectum or colon. Polyps are small growths that can expand and become cancerous over time. A polyp size of greater than one centimeter or the formation of multiple polyps signifies an increased risk of cancer occurring.

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    What Colorectal Cancer Screening Tests Does Medicare Cover

    Cologuard vs Colonoscopy (Pt. 2)

    Medicare covers the following tests, generally starting at age 50:

    Fecal occult blood test or fecal immunochemical test once every 12 months.

    Stool DNA test every 3 years for people 50 to 85 years old who do not have symptoms of colorectal cancer and who do not have an increased risk of colorectal cancer.

    Flexible sigmoidoscopy every 4 years, but not within 10 years of a previous colonoscopy.


    • Once every 2 years for those at high risk
    • Once every 10 years for those who are at average risk
    • 4 years after a flexible sigmoidoscopy for those who are at average risk

    Double-contrast barium enema if a doctor determines that its screening value is equal to or better than flexible sigmoidoscopy or colonoscopy:

    • Once every 2 years for those who are at high risk
    • Once every 4 years for those who are at average risk

    At this time, Medicare does not cover the cost of virtual colonoscopy .

    If you have questions about your costs, including deductibles or co-pays, its best to speak with your insurer.

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    I Learned The Hard Way That Colon Cancer Is On The Rise Among Younger People

    But many gastroenterologists like me are concerned about the referral cases were seeing for follow-up colonoscopies triggered by positive Cologuard tests, especially those in which Cologuard should not have been prescribed in the first place. Many of us are also concerned that an outsized focus on convenience is overshadowing serious limitations of the test.

    For me, its personal. I will never forget trying to find the right words to comfort my uncle who was dying from colon cancer a disease I have spent my professional life trying to prevent.

    There are four main ways to screen for colorectal cancer. Colonoscopy is the gold standard. It uses a flexible, lighted tool called a colonoscope to view the entire colon and remove cancerous and precancerous growths called polyps if they are detected. CT colonography uses a CT scanner and computer programs to create a three-dimensional view of the inside of the colon and rectum that can be used to identify polyps or cancer. Another method is the fecal immunochemical test , which checks stool for tiny amounts of blood given off by polyps or colorectal cancer. Cologuard tests stool for tiny amounts of blood as well as for certain abnormal sections of DNA in cells shed by cancer or polyps that end up in the stool.

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