Does Insurance Cover Endoscopy and What You Need to Know

Insurance coverage for endoscopy varies depending on the type of procedure and your individual policy.

Most insurance plans cover diagnostic endoscopy, which is used to identify the cause of symptoms.

If your doctor orders an endoscopy for a medical condition, the procedure is likely to be covered.

However, if you're having an endoscopy for a cosmetic reason, such as removing polyps for aesthetic purposes, it may not be covered.

Insurance coverage for endoscopy and colonoscopy varies depending on your health plan. If you have a health plan that started on or after September 23, 2010, you're in luck - it's likely to cover colorectal cancer screening tests, including endoscopy and colonoscopy, with no out-of-pocket costs.

Medicare also covers these tests, but only if they're medically necessary or part of preventive care. If you're scheduled to have both an endoscopy and colonoscopy during the same visit, Medicare can cover both procedures.

Medicaid coverage for colorectal cancer screening varies by state, with some states covering fecal occult blood testing (FOBT) and others requiring a doctor's determination of medical necessity.

Some states cover colorectal cancer screening only 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.

There's no federal assurance that all state Medicaid programs must cover colorectal cancer screening in people without symptoms.

Colonoscopy and Endoscopy can be covered by insurance, but it's essential to understand the specifics of your coverage. Many private insurance plans cover the costs of colonoscopy as a screening test, although you might still be charged for some services.

If you have Medicare, you're in luck - most colorectal cancer screening tests are covered at no cost, including FOBT/FIT, stool DNA test (Cologuard), colonoscopy, and flexible sigmoidoscopy. However, if a polyp is removed or a biopsy is done during the colonoscopy, you may have to pay 15% of the Medicare-approved amount for your doctor's services.

Medicare Part B covers outpatient healthcare, including endoscopy, and you pay 20% of the cost of the procedure after meeting your yearly deductible. The estimated cost of an upper endoscopy depends on where it's performed, ranging from $191 to $392.

Here's a breakdown of the costs associated with endoscopy and colonoscopy under Medicare:

A colonoscopy can be either preventative or diagnostic, and it's essential to understand the difference to avoid surprise costs.

If you're 50 or older and have no personal history of gastrointestinal disease, colon polyps, and/or cancer, your colonoscopy is likely a routine screening and covered by most insurance plans.

Some insurance carriers consider surveillance or high-risk colonoscopies to be preventative, while others consider them diagnostic, so it's crucial to ask your insurance provider.

You should obtain the pre-procedure diagnosis code from the scheduler or medical assistant before your procedure to determine if your colonoscopy is covered under your policy and if it will be processed as preventative or diagnostic.

If your procedure will be considered diagnostic, the allowable amount will be allocated to your deductible, and you'll need to contact the CRS Business Office for an estimate of what you can expect to pay.

The physicians at CRS cannot change the primary diagnosis for the sole purpose of coverage determination, so it's essential to provide accurate information during the pre-procedure assessment.

Endoscopy can be a crucial diagnostic tool for various health issues, including colorectal cancer.

Medicare Part A covers endoscopy if you're hospitalized, but you'll need to pay the deductible for each hospital stay before it starts to pay.

The 2025 Medicare Part A deductible is $1,676.

If you get an endoscopy as an outpatient procedure, Medicare Part B covers it, but you'll pay 20% of the cost after meeting your yearly deductible, which is $257 in 2025.

The estimated cost of an upper endoscopy varies depending on where it's performed:

It's essential to review your insurance plan to understand what's covered and what you might need to pay out-of-pocket for endoscopy services.

If you're planning to undergo an outpatient endoscopy, it's essential to understand the costs involved. Medicare Part B covers outpatient healthcare, but you'll still need to pay 20% of the procedure cost after meeting your yearly deductible, which is $257 in 2025.

The cost of an upper endoscopy varies depending on where it's performed. At a non-hospital (ambulatory) surgical center, the estimated cost is between $191 (flexible) and $196 (rigid). In contrast, a hospital outpatient surgical center may charge between $387 (flexible) and $392 (rigid).

To give you a better idea of the costs, here's a breakdown of the estimated costs for an upper endoscopy at different locations:

Keep in mind that these costs are estimates and may vary depending on your specific situation and location. It's always a good idea to check with your healthcare provider or Medicare for the most up-to-date information on costs and coverage.