Health Insurers Must Cover Polyp Removal for Preventative Colonoscopies No more out-of-pocket surprises for patients undergoing this lifesaving procedure

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Preventing Colorectal Cancer (PCC) applauds the U.S. Departments of Labor, Health and Human Services (HHS), and the Treasury (the Departments) for determining that polyp removal should be a covered procedure in a provision of the Patient Protection and Affordable Care Act (PPACA) that requires coverage of preventive care, including screening colonoscopies, by insured and self-funded health benefit plans with no out-of-pocket cost to patients

Polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure.

Preventing Colorectal Cancer (PCC) applauds the U.S. Departments of Labor, Health and Human Services (HHS), and the Treasury (the Departments) for determining that polyp removal should be a covered procedure in a provision of the Patient Protection and Affordable Care Act (PPACA) that requires coverage of preventive care, including screening colonoscopies, by insured and self-funded health benefit plans with no out-of-pocket cost to patients.

This PPACA provision originally was interpreted by certain health benefits payors to apply only if the colorectal cancer screening colonoscopy found no polyps requiring removal. In cases where a polyp was found and removed, the procedure then became a polypectomy and some payors applied the full range of copays and deductibles. Colorectal cancer screening advocates, including PCC, have worked tirelessly since PPACA’s induction urging federal regulatory personnel for a more reasonable and patient-friendly interpretation of this provision and this recent announcement reflects their efforts.

The Departments jointly prepared a list of Frequently Asked Questions (FAQs) that includes the statement, “Polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure.”

“Thanks to this determination, patients covered by health insurance or self-funded health benefit plans will no longer face the prospect of needing to undergo this potentially life-saving procedure, but having no idea how much it would actually cost until the procedure was completed. Now all payors will have to cover a colorectal cancer screening colonoscopy as a preventive service, with no out-of-pocket expense to the patient,” says Steven J. Morris, MD, FACP, PCC board chair and president, Atlanta Gastroenterology Associates.

“This is one of the deadliest forms of cancer and is considered the second-leading cause of cancer deaths, which is disturbing because colorectal cancer is also one of the most easily prevented forms of cancer,” Morris says.

“A cancer prevented is better than a cancer cured,” notes Stanford Plavin, MD, PCC vice chair and president and managing partner, Ambulatory Anesthesia of Atlanta. “The opportunity to remove polyps before they become cancerous exists when patients receive the ‘gold standard’ screening, a colonoscopy.”

Founded in 2008, PCC’s mission is to educate the public and key stakeholders about the opportunities to reduce the incidence of colorectal cancer through maintaining screening and care options for patients and their clinicians.

About Preventing Colorectal Cancer: Headquartered in Annapolis, MD, Preventing Colorectal Cancer preserves the tradition of safe, comfortable and quality-based medicine. PCC is a not-for-profit 501(c) 6 advocacy organization with its primary mission to educate both public and private stakeholders about the opportunities to reduce the incidence of colorectal cancer through promoting effective screening, prevention and care options for patients.

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Randall Madry
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