Changes to Colorectal Cancer Screening Guidelines: What You Need to Know

Last month, the American Cancer Society (ACS) changed its guidelines for recommendations of preventive colorectal cancer screening. The ACS now recommends that people of “average risk” begin screening at age 45 – a change from the previous age 50 recommendation.

Average risk persons include those who do not have:

  • A history of colorectal cancer or certain types of polyps
  • A family history of colorectal cancer
  • A personal history of inflammatory bowel disease like ulcerative colitis or Crohn’s disease
  • A confirmed or suspected hereditary (genetic) colorectal cancer syndrome like familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary non-polyposis colon cancer/HNPCC)
  • A personal history of getting radiation to the abdomen (belly) or pelvis as part of treatment for a previous cancer

However, the recommendations for when to begin screening vary amongst organizations. As part of the Affordable Care Act (ACA or “Obamacare”), certain preventive procedures must be covered at 100% by all insurance plans. This includes routine colorectal cancer screening. The website currently states that this procedure should be covered for persons at average risk, ages 50-75. The US Preventive Services Task Force (USPSTF) recommends screening begin at age 50 and this is the guideline most insurers follow.

Well, I’m 46. And I’m “average risk.” So, is time for me to begin my colorectal cancer screening?

While I’m a firm follower of ACS guidelines for cancer prevention, I was concerned that perhaps my insurance company was not.

This concern was confirmed with a call to my insurance provider this morning.

My provider does not recognize the new age recommendation from the ACS. Their guidelines continue to be to begin preventive screening at age 50. This means if my provider ordered the colonoscopy or other screening test for me and it was billed under a preventive screening code, it would NOT be covered.

But…the representative from my insurance company dug a little deeper. If I were to receive this procedure at an in-network facility under my “outpatient surgical benefit” it will be covered at 100%. But, it must be billed under that benefit…and I need to have a “need” for ordering said procedure like “bleeding” or “pain.”  The reason cannot be preventive screening. Since I don’t have any symptoms associated with heightened colon cancer risk at this time, I don’t feel certain this procedure would be covered for me under my plan. I will wait to see if my plan updates their coverage perimeters based on these new recommendations.

So, the lesson here is—if you are 45 and considering colorectal cancer screening based on these new ACS guidelines, you MUST call your insurance company first to determine if and how this service may be covered.

Key questions to ask when you call:

  • “The American Cancer Society now recommends routine colorectal cancer screening begin at age 45. Does my plan cover this, based on my age, as a preventive care procedure?”
  • “If it is not covered as a preventive procedure, are their other options for me to receive this screening test that will be covered by my plan?”
  • “What are my out of pocket responsibilities if I have this procedure?”

Remember to get the name of the representative you talk to, as well as record the date and time of your call.

The ACS recommendation to begin screening is just that, a recommendation. Talk with your healthcare provider about screening options and plans as part of your annual healthcare visit. Remember, “an ounce of prevention is worth a pound of cure.”

One thought on “Changes to Colorectal Cancer Screening Guidelines: What You Need to Know

  1. I just had my second colonoscopy. No polyps. The doctor said I have the colon of a 20 year old. I thought was covered like the first one was five years ago. The insurance company says I have to pay because of a family history of cancer. That was my last colonoscopy.

    Insurance companies are evil.

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