Does Medicare Cover an Endoscopy? 

The inner workings of the human body are incredibly complex, but thankfully, modern medicine offers a number of imaging options to get a better view of the body’s organs and systems. X-rays, computed tomography (CT) scans and magnetic resonance imaging (MRI) tests can all provide an in-depth view of the body’s interior, but these technologies are limited. If a doctor really wants to get an up-close-and-personal look at what’s happening inside your body, they will perform an endoscopy.

What is an endoscopy?

An endoscopy is a medical procedure that involves placing a thin, flexible tube down your throat. This tube, known as an endoscope, has a lighted camera attached at one end, and its movement can be controlled remotely. This camera broadcasts video back to a monitor where medical personnel can see what the camera captures in real-time. Newer methods of endoscopy use a small pill-sized camera that is swallowed. As the camera passes through the digestive tract, it can broadcast information back to a doctor. This is referred to as capsule endoscopy.

During a traditional endoscopy, you may or may not be sedated. If you are not sedated, you will be given a numbing spray on the back of your throat to reduce or eliminate your gag reflex. Most endoscopies are performed in an outpatient setting, and the actual procedure itself generally takes less than 20 minutes; however, preparation for an endoscopy can take up to eight hours since you can’t eat or drink anything for a period of time before the procedure.

When is an endoscopy performed?

An endoscopy is often performed when a physician needs to investigate the gastrointestinal (GI) tract, including areas of the esophagus, stomach and small intestine. This is referred to as an upper endoscopy since the procedure involves investigating the upper GI tract. A lower endoscopy is referred to as a colonoscopy. This procedure involves inserting an endoscope into the rectum to investigate the large intestine and colon.

In cases where internal bleeding is suspected, an endoscopy can help to pinpoint the exact location of a bleed. Likewise, an endoscopy may be performed to monitor the progress of a condition or the healing of an injury. Endoscopies may also be performed when medical imaging is inconclusive and to avoid exploratory surgery. 

Does Medicare cover an endoscopy?

Seniors, retirees and Medicare recipients will be happy to know that Medicare coverage does supply benefits for an endoscopy in several ways. Since most endoscopy procedures are performed in an outpatient setting, Medicare Part B is used to help pay for an endoscopy in most cases. Under Medicare Part B, the cost of an endoscopy is covered at 80% by Medicare as long as the procedure is deemed medically necessary and is performed by a Medicare-participating physician or specialist.

Inpatient coverage of endoscopy procedures under Medicare

If an endoscopy needs to be performed while you are staying as an inpatient in a Medicare-approved hospital or skilled nursing facility, Medicare Part A covers the procedure. In this case, the entire cost of the procedure is covered by Medicare benefits. Medicare Part A only covers 60 days of hospital care per benefit period or 20 days of care in a skilled nursing facility.

During these periods, the full cost of inpatient care is covered, and additional days of coverage may be available by paying a per-day fee. Hospital care can be extended to 90 days, and skilled nursing facility care can be extended to 100 days.

Medicare Part D and endoscopy coverage

Medicare Part D supplies prescription drug coverage to Medicare recipients. If you are prescribed medications to take as a result of something found during your endoscopy, Medicare coverage under Part D may help pay for prescription drugs that are listed in your plan’s formulary and are available for purchase from a traditional neighborhood pharmacy.