Affordable Care Act: Not all colonoscopies are “preventive”

I would like to see you do research and topic of colonoscopy on patients that have been diagnosed with ulcerative colitis previously.  Getting insurances to cover for these people is not good.  They have to pay their high deductibles,(mine is $2500)therefore really is not affordable for most. Insurances feel that colonoscopies are diagnostic not preventive or these people.  Ulcerative colitis is an autoimmune disease and having this puts you at a higher risk for colon cancer however insurances do not feel that it is preventive medicine!  It is standard of care and strongly advised for UC patients to undergo a colonoscopy every 2 years and during those colonoscopies it is standard procedure to do biopsies every so many cm (approximately 32 biopsies).  Is this discrimination?  I do not feel that the general public realizes that the insurance companies do this until they are faced with this personally.


You are bringing out a fine-print detail about the difference between preventive and diagnostic tests. Under the Affordable Care Act, health insurance has to cover preventive tests – including the colonoscopy for people age 50 to age 75 – without charging a co-pay. A test is “preventive” if the patient has no symptoms of disease. The very same test can be “diagnostic” if the patient has symptoms, or in your case, risk of disease.

Insurers are not required to cover preventive (or “screening”) colonoscopies more frequently than the United States Preventive Task Force recommends. Their guidelines suggest every 10 years for colonoscopies.

So, while ulcerative colitis patients may need colonoscopies more frequently, the insurer does not have to cover it with no co-pay. From a clinical definition, the higher frequency of the test means that it is not preventive.

You can press the issue with the insurer, by appealing when they deny the claim or charge you the co-pay. Another thing that Health Reform requires is a three-level appeal process, with independent people reviewing your claim and your argument. See HHS’s step-by-step process for appeals. It’s possible that the review will lead to better coverage for your test.

See also my fellow blogger, Diane Atwood’s Catching Health posts on colonoscopies.

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Linda Riddell

About Linda Riddell

A published author and health policy analyst with 25 years’ experience, Linda Riddell's goal is to alleviate the widespread ailment of not knowing what your health plan can do for you.