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Pay out of pocket for preventative care?
April 25, 2014 8:57 AM   Subscribe

Colon Cancer scare in my family. My health insurance won't cover a colonoscopy because I'm too young and have no symptoms. Should I shell out the $1000 - $3000 this could cost me to get checked? Gratuitous YANMD.

Ok, here's what's stacked against me:
-grandfather died of colon cancer
-dad started having pre-cancerous polyps removed at 44
-3 year younger sister just got a polyp removed (non-cancerous) - that's what triggered family freaking out
-lots of diverticulitis in family
-lots of other random cancer in family
-health insurance won't cover until I'm 50
-Hospital will charge in the $1000 - $3000 range, I suspect I make too much to get any financial assistance

In my favor:
-I'm really healthy otherwise and have no real symptoms of anything

So, what would you suggest? I'm not actively freaking out or anything, but it irks me a bit that I can't get checked until I'm pooping blood. BCBS has flat out told me they will pay zero for the coding of a colonoscopy for family history at my age. Is there any way around this with another procedure or another code (talked to doctor, they have told me they won't change the code but maybe I'm missing something)? Should I just suck it up and pay? Opinions and advice please!
posted by ashtabula to opelika to Health & Fitness (26 answers total)
 
I would suggest not having a colonoscopy. The odds of them discovering something that needs to be dealt with are extremely low. I think the reason your insurer and your doctor are telling you the test isn't indicated is because it really isn't indicated.
posted by escabeche at 9:01 AM on April 25 [7 favorites]


My health insurance won't cover a colonoscopy because I'm too young and have no symptoms.

Your answer is right there in your question.
posted by NotMyselfRightNow at 9:03 AM on April 25 [5 favorites]


You are asking MF to give you specific medical advice about whether you should have a procedure that does carry with it some risk. MF generally won't specifically answer that kind of question.

I see you are 36 yo. Given your family history, did you ask the doctor or the insurance company what age you would have to be for this procedure to be covered? My doctor once told me that when dealing with "family history" they are talking about immediate family--like parents and siblings. Grandparents, aunts, uncles---all too far removed to matter.
posted by Seymour Zamboni at 9:04 AM on April 25


And I just wanted to add...if you are unsatisfied with your doctor's response to your concerns, then maybe you could seek a second or third opinion about whether or not a colonoscopy is warranted for somebody in your position.
posted by Seymour Zamboni at 9:07 AM on April 25 [1 favorite]


Does your doctor recommend that you get a colonoscopy, but insurance won't cover it? If so, enlist your doctor's help to fight the insurance.

If your doctor doesn't recommend it, follow the doctors advice and wait. Or seek a second opinion if you want - but I wouldn't pay out of pocket for a test my doctor doesn't think I need.
posted by insectosaurus at 9:08 AM on April 25 [2 favorites]


I have a family history of colon cancer, breast cancer and ovarian cancer (HELLO BRCA!)

I was always able to get appropriate tests based upon my physicians say-so.

I will say, that although I've had ultrasound and 3-d imaging and a prophalactic hysterectomy at 41, that I was told to wait until the age of 50 to start with colonoscopy.

So, even with my scary, scary history, my doctors agreed (more than 1) that now is the appropriate time.

But go to a genetics counseling doctor for a second opinion. If a doctor deems it medically necessary or recommended, then your insurance should pay for it.
posted by Ruthless Bunny at 9:12 AM on April 25


Should I shell out the $1000 - $3000 this could cost me to get checked?

IANAD, and I do not think it sounds necessary at all, but I'm also not prepared to say that $1-3K isn't worth it to you if it give you peace of mind. A friend (who is also a nurse) did one of those genetic testing things and found out he is likely? prone? to getting macular degeneration, which does run in his family.

My suggestion to you would be to take your family history seriously and modify your lifestyle in ways that could help mitigate any future medical problems you may be worried about.
posted by Room 641-A at 9:15 AM on April 25


it irks me a bit that I can't get checked until I'm pooping blood

It's entirely likely that your theoretical colon cancer would not be detectible via colonoscopy until about that point anyway. A colonoscopy today only tell you that you don't have cancer today. It's not a preventative procedure - it prevents nothing - and you can't have one every 6 months. (I mean, I suppose someone could, but BCBS isn't going to pay for that either.)

Maybe you should have a conversation with your doctor or another GI specialist about an ongoing plan rather than focusing on one procedure.
posted by Lyn Never at 9:16 AM on April 25 [3 favorites]


Yeah, Lyn Never really has it here - OK, so you get a colonoscopy today... how often are you planning to get this procedure done? If you're 35 are you going to pay $1000-3000 every year until your insurance starts covering you at 50?

I think a lot of people (patients and doctors alike) have this idea that if we could just detect diseases as soon as they start nothing bad would ever happen, but unfortunately this is just not the case.
posted by mskyle at 9:26 AM on April 25


Have you talked to your doctor? If you have a first degree relative (dad) with cancer OR high risk polyps (based on size, type, other factors) then some recommend starting screening colonoscopies 10 yrs prior to the age when the first degree relative was diagnosed. Starting at age 50 is for average risk individuals, without symptoms or concerning family history.
So, your family history does raise some red flags. I wouldn't recommend rushing out to pay out of pocket. Get in with a GI; he/she will know screening criteria, and if you meet them will be able to make the case to your insurance company.
posted by maryrussell at 9:30 AM on April 25 [1 favorite]


A flexible sigmoidoscopy is a procedure that can be performed in your doctor's office, without the lengthy prep associated with a colonoscopy, and without sedation (really, it is not bad at all). It is also significantly cheaper (especially because it doesn't require sedation), and while it is not equivalent to a colonoscopy, it is very good at improving colorectal cancer outcomes.

I'm suggesting this as a compromise because you seem very unsettled. Personally I don't believe you need any kind of endoscopic procedure (in other words, I agree with your doctors and insurers), however, this is a low cost, less invasive test that might put you more at ease, without breaking the bank.
posted by telegraph at 9:37 AM on April 25 [1 favorite]


My health insurance won't cover a colonoscopy because I'm too young and have no symptoms.

Make sure you understand exactly what they're saying. It's possible that they're refusing to provide any coverage for this whatsoever. But it seems more likely to me that they're simply refusing to classify it as qualifying preventative care, instead classifying it as elective care for which coverage is provided per the other terms of the policy. If you have a deductible you haven't met yet, you'd still have to shell out for it, but they'd still adjust the claim and credit that expense towards the deductible.

Also, if you can get a physician to order the exam for you as medically necessary, the company would have a really hard time avoiding coverage for it. It'd go under the main coverage portion of the policy, not preventative care, but you'd still get coverage.

So look into your benefits a little more closely to see if you can figure out exactly what's going on. You may be better off here than you think.
posted by valkyryn at 9:53 AM on April 25 [3 favorites]


Do they mean that it won't be covered at all, or do they mean that it won't be covered as preventative care? Because those are two different things. It's unclear from your question which this one is. (If it's covered but you're paying for it because it's under your deductible, at least you have the advantage of BCBS negotiated rates, which are much lower than off the street rates.)

Also, this probably depends on the insurance coverage details (and only applies if they are counting it under the deductible but not as preventative), but there may be a difference between a medical procedure done in a clinic vs. in a hospital. I have had "clinic" procedures done for the cost of a copay only that would have been $$$ if I had had the exact same procedure done in a "hospital." Obviously this may not work for you (for example, if you pay the full cost of dr's visits up to your deductible), but it might be worth asking around.

Also! It's worth considering that even if you were fifty, your insurance probably won't cover this as "preventative" care in the end. Most insurance companies will take ANY finding -- even one as minor as diverticulosis (which it sounds like you have an increased risk of) or minor hemorrhoids or similar completely non-threatening things -- and use it as a reason to *retroactively* re-code your procedure as "diagnostic," since hey, it was used to diagnose your diverticulosis! (This is something BCBS does to people on my policy. AWESOME, no?)

Good luck -- it sounds very stressful to deal with.
posted by pie ninja at 9:59 AM on April 25


According to the American Cancer Society, someone with your family history should be getting colonoscopies at 5 year intervals. This is NOT a yearly exam.

See if you and your doctor can pressure the insurance company into covering it. If that fails, you can probably afford to budget up $250 a year towards a colonoscopy every 5 years.

Put your mind at ease for less than a dollar a day. Get it done.
posted by maudlin at 10:11 AM on April 25 [1 favorite]


Obviously there is no one size fits all advice, but I am at very high risk for colon cancer due to my family history. Still I've been told I don't need one until I'm 40 and that is the exact same advice that was given to other family members by other doctors.

I have multiple family members who get one every year and insurance covered it even before they were 50, but I assume it was specifically ordered my their doctor.

If you are really concerned, go to a specialist, explain to them your family history and ask what steps you should be taking now and in the future to mitigate your risk.
posted by whoaali at 10:13 AM on April 25


Crap -- math error! Would be up to $600 a year, less than $2 a day. The low estimate would be $200 a year.
posted by maudlin at 10:14 AM on April 25


I think a lot of people (patients and doctors alike) have this idea that if we could just detect diseases as soon as they start nothing bad would ever happen, but unfortunately this is just not the case.

Well, sure, in the grander scheme of the limits of medicine and the fact of our mortality, this is absolutely true. But in this particular case of detecting colon cancer, however, catching it in the polyp stage is far better than waiting till it progresses -- though I am biased on that score, having been "too young" to get colon cancer and nevertheless had it diagnosed at Stage II at the age of 40 (and this with absolutely no family history of it whatsoever). Had I had a colonoscopy in my mid-30s, it's very likely they would have caught it at the polyp stage and I would have been spared 14 months of treatment and 2 years of post-treatment complications.

Given the OP's family history, I would personally advise getting the scope (though again, I admit that I am biased). It doesn't even necessarily have to be right now; OP, if you have a flexible spending account option at your workplace, maybe you could enroll for next year (it's too late to do it for 2014) and save for all or part of the cost of the procedure that way (and it's pre-tax money, so it will help lower your overall tax liability for the year).

Also, while it's true that the vast majority of cases of colon cancer occur in people over 50, the incidence rate among people under 50 has been increasing. So the "no colonoscopy till 50 under any circumstances" rule that some insurance companies have shouldn't be taken as indicative that it's really never necessary for anyone under 50.
posted by scody at 10:21 AM on April 25 [2 favorites]


My mother had colon cancer many years ago (and is fine today BTW). My doctor asked me what age she was when she was diagnosed and then subtracted 10yrs from that and told me that was the age for me to have my first colonoscopy. So I had my first one done at the age of 48 because there were indicators that it should be done before the standard age of 50. There are no indicators for you according to your doctor. Pre-cancerous or non-cancerous polyps are not colon cancer. You don't have the family history or the symptoms to warrant a paid-for procedure at this point. This is good news.
posted by ThatCanadianGirl at 10:42 AM on April 25


I have a family history, and I was covered at 32. My brother first had polyps discovered at 38 or 39, and I had them just recently at 42. In fact, I'd procrastinated a couple of years longer than I should have, and one of the three was fairly large, and believe you me, I will be right on time when I get my next colonoscopy done in 2 years. I totally sympathize with anyone with a family history wanting a colonoscopy, and if it were me (well, the me of today, obviously not the procrastinating me of several years ago), I would absolutely pay out of pocket if need be.
posted by instamatic at 11:09 AM on April 25


Get genetic testing if possible first for your dad and sister. If they have one of the common mutations, then get yourself tested for it. If they don't, then pay out of pocket for the colonoscopy, so you can ease your mind.

Family history here too, with close relatives who got it in their 30s. Before genetic testing for our family's gene variant became available in about 2000, I had to assume that I was living with the colon cancer mutation. I was in my 20s and had several general scares. Having my first colonoscopy (which was totally clean) did wonders to ease my mind. I had to pay out of pocket (with some help from family) and have absolutely no regrets. Good luck to you.
posted by oxisos at 11:36 AM on April 25


My doctor said what ThatCanadianGirl said. 10 years before my dad got it, which would have been 2 years ago. He is the one who said I should do it. I'm not dying to have a colonoscopy - trust me. I have a phone call in to talk to him, so hopefully we can figure something out.

Thanks!!!
posted by ashtabula to opelika at 11:51 AM on April 25


If your doctor doesn't recommend it, then don't have a colonoscopy.

If, on the other hand, your doctor DOES recommend it, then your insurance should cover it. Have the doctor call the insurance company and tell them WHY he or she thinks you should have one. A doctor's recommendation should help you immensely with the insurance company's BS.
posted by tckma at 12:26 PM on April 25


You need to have your doc send you to a geneticist.
The geneticist can evaluate your risk and help you plan appropriate testing, and will have the ability to prove your risk level to your insurance company.
posted by littlewater at 10:08 PM on April 25


My doctor said what ThatCanadianGirl said. 10 years before my dad got it, which would have been 2 years ago. He is the one who said I should do it. I'm not dying to have a colonoscopy - trust me. I have a phone call in to talk to him, so hopefully we can figure something out.


Colonic polyps are not equivalent to cancer even if pre-malignant. They can be stratified into low to high risk depending on how large they are and what they look like under a microscope. If you sister had low risk polyps, be aware that these things can take a years and years to turn into cancer.

Current screening guidelines suggest screening 10 years before onset of colon cancer in a first degree relative or from the age of 40 whichever comes earlier.

However, if you are proven to carry a Hereditary Nonpolyposis Colon Cancer (HNPCC) related gene mutation, screening is recommended from your early 20's.

A colonoscopy is not risk free. The risk of malignancy needs to be balanced out against a 1 in 1000 risk of intestinal perforation requiring surgical repair that may kill you.

Well, what I am trying to say here is risk stratification is the key. Speak to your doctor whether you might need a geneticist / GI specialist consult to stratify your risk accurately and take it from there.
posted by ianK at 3:27 AM on April 26


A colonoscopy is not risk free. The risk of malignancy needs to be balanced out against a 1 in 1000 risk of intestinal perforation requiring surgical repair that may kill you.

This. You also want to make sure your insurance will cover any bad outcomes of the procedure -- perforation's serious business, and not uncommon.
posted by asperity at 8:17 AM on April 26


Soon, you may be able to test for colon cancer at home. Not sure what the cost would be, though.
posted by potsmokinghippieoverlord at 4:06 PM on April 26


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