Insurance Coverage for Colonoscopy

Dr. Timothy Hoops
Last Modified: November 1, 2001

Dear OncoLink "Ask the Experts,"
I am writing on behalf of my brother. He is 58 years old and has never had a colonoscopy. My mother had breast cancer that metastasized to her colon, requiring a colostomy. She died in 1984. My father has recently been diagnosed with colon cancer detected on a colonoscopy. He only had that one because he had two episodes of bleeding. The GI physician, after performing the colonoscopy, told my two brothers that they should both have colonoscopies immediately. My older brother got a referral from his PCP to see a GI physician, had the consultation with the GI doctor, and set a date for a colonoscopy. He was contacted earlier this week and told that the insurance company is denying payment for the colonoscopy. They said they would only pay for it if there was "active bleeding." What should he do in this situation? He obviously needs the colonoscopy with such a strong family history and being 58 years old, and his PCP agreed, or he would not have referred him in the first place. What can anyone do in a situation such as this?  
Thank you,

Dr. Timothy Hoops, Clinical Assistant Professor of Medicine in the Gastroenterology Division at the University of Pennsylvania and Director of Gastroenterology at Penn Medicine at Radnor, responds:

Dear MB,
Coverage of colonoscopies by insurance companies has become an increasingly larger problem. Many companies are now covering "screening" colonoscopies for patients that are not above average risk for the disease. The rationale is that this procedure is more complete. It may also be safe to do this procedure once every 10 years. People who have a family history of colon cancer such as your brother have an increased risk for the development of colon cancer reaching 10 to 15% over their lifetime. Most gastroenterologists would recommend a full colonoscopy for these patients as the entire colon can be evaluated and if polyps are found, they can be removed. Alternative recommended screening methods include flexible sigmoidoscopies every 5 years and annual tests for occult blood in the stool. The opinion of many experts is that this may be a somewhat less effective method for screening these patients with an increased risk for colon cancer.

Unfortunately, health care insurers use many criteria to determine how they cover certain services. Discussion of the specific issues regarding risk may cause them to change their policy for an individual. It should be stressed that any symptom such as a change in bowel habits or any rectal bleeding can then be used as a justification for the procedure. Finally, it is our hope that these policies will be changing in the near future as more public support is generated for better screening techniques.