Colonoscopy and insurance

A little background: I was in remission for two years and on no medications until last October when I started flaring. I started seeing a new doctor and he wanted to do a colonoscopy to see what was going on and since I hadn't had one in about six years. Originally my insurance denied my claims due to a pre-existing condition but they finally approved my waiver after I proved that I had not been treated in the six months prior to my enrollee date with them. I'm just now sorting through all of my bills from the procedure and I questioned my insurance as to why my policy says I'm allowed one colonoscopy a year, yet I've been billed (after insurance) about $1500.00. Their response was that the procedure goes from preventative to diagnostic as soon as polyps are detected so they won't cover the procedure unless it's preventative. This is such BS! They said I could appeal it but after doing some reading online, it sounds like this is a well known issue in the medical/insurance world where the patient gets screwed if a polyp is found. I still plan to send a letter but it doesn't sound like I'll win the appeal.

Does anyone have experience with this?

Thanks for the support! I do plan to appeal it, as I've appealed many claims in the past. It's just so frustrating that just because I have polyps, my procedure is not covered. They still have to administer the same anesthesia, have the same nurses with me, do the same procedure whether I have polyps or not. I can see that the biopsies would not be covered but the procedure itself is the same no matter what. I'm just not sure how to word my appeal.

Two issues. Finding a polyop doesn't usually allow insurance companies to disallow coverage as preventive but it happens all the time. My insurance covers if you have no medical condition and have no symptoms. I think this might be AZ state law.

But UC diagnosis means colonscopy is going to be a major battle to get it covered under preventative services which have no deductible with my insurance plan because UC is a medical cause for colonscopies . I have heard that colonscopies slip through as preventive care with no deductible but it is because the insurance company isn't checking. I personally feel that doctors who take "peeks" and don't follow the guidelines with regard to frequency of colonscopies are major contributor to the problem. I don't think a new patient in remission should get a colonscopy automatically but they all seem to insist on it. My last GI required colonscopies for all UCers every year and every six months if any inflammation is detectable. I refused and walked out the door. Apparently others did the same thing because he left the practice and the state.

It depends what your policy actually says and what the laws are in your state. I am hoping once the state insurance market places are running next year that I can switch to a low deductible plan and avoid this nightmare. I still will refuse colonscopies unless they are by the book as far as frequency and for cancer surveillance only.

My 2nd scoping 18mo after the 1st was covered 100% by Blue Cross, but I am not sure why. It was certainly diagnostic for UC, because we wanted to see how the inflammation pattern had changed. However it might have been preventative for colon cancer screening. I was afraid to ask in case they decided the 100% was a mistake.

As much as insurance company behavior and details of policy language can suck, I think it is important to acknowledge that it was "covered". Companies have begun to waive deductibles and co-pays for many preventative procedures (because prevention is cheaper in the long run). Technically you are complaining that you have to pay the usual deductible and co-pay for you policy, and that you are not getting the "preventive" freebie. But it was not preventative.

Anyway, UC sucks, the cost of meds sucks, the cost of tests like scoping sucks. The behavior of insurance companies sucks. I agree it all sucks. But they did cover it at the usual rate.

That being said, since it was six years after your diagnosis or previous scoping, I would argue that the scoping was consistent with recommendations for routine yearly colon cancer screenings starting 6 or more years after diagnosis.

We all know this is not true. You just said the GI wanted to see what was going on with UC. But, generally I think you can try to claim it was not diagnostic for UC, but the 1st of recommended regular screenings for colon cancer. Might work.