Did your insurance cover Pouchoscopy

Good question.

Most insurance companies must cover a screening colonoscopy every 10 years after age 50.  If a diagnosis is put down for whatever reason, it becomes a diagnostic colonoscopy subject to deductibles and copays.

Check with the insurance company, but I think (and I could be wrong), your physician is not going to be able to pass this off as a screening.

My first pouchoscopy was covered by my commercial insurance (I am on Medicare now), and it was subject to my high deductible (which was already met)

If it's coded properly then your deductible will probably be applied. Colonoscopies are part of a specific set of preventive services that were carved out under the ACA to remove the financial obstacles (e.g. deductibles) to getting them done. A screening colonoscopy is intended to catch dysplasia or colon cancer early to prevent advanced cancer from developing. Pouchoscopies are useful procedures, but they aren't equivalent to a colonoscopy for this purpose.

I have had annual pouchoscopies (due to Chronic inflammation and dysplasia in colon when removed) for 30 years plus since getting a J Pouch.  In 30 plus years I never had ANY insurer deny coverage for the annual scope.  I just went on a new insurance plan with Anthem effective July 1, 2023 and the authorization letter came in the mail the day after my pouchoscopy, which was on July 10. Yale obviously had gotten the electronic authorization before the procedure.

If there is no chronic inflammation or dysplasia in the history, I have heard GI opinions ranging from 3-10 years on the timing of the scoping.  Whether an insurer would agree depends on how it is presented by the GI as to the need for it.  I am not sure if there is a specific industry standard as to the timingof the interval of scoping of a non-symptomatic pouch with no inflammation and no dysplasia history, other than to say about 3-10 years.  Reasonable minds can differ and perhaps reasonable insurers of health can also differ on this issue.  Age would be a factor. Once you hit age 50, the timing of scoping of colons with no disease changes, and probably should as well for J Pouches given that colonic tissue is present in the form of the rectal cuff.

I am scoped annually - history of high grade dysplasia in the descending colon.  During my procedures I've also had banding and balloon dilation.   The Insurance (Aetna and Anthem respectively) covered each time - so far.

Its covered by my insurance, Medical Mutual, but is subject to my deductible which is crazy high.  i had my jpouch due to uc and low grade dysplasia, i am supposed to get scoped every year but cannot afford to pay $3500.00 out of pocket every year on op of my other health bills and rest of family. I had my first pouch in 2008 and redo in 2015. biopsies have been clear since first surgery. Dr Remzi said i could get mine every other year so trying to stay on that schedule.

Thank you everyone.  I’m pretty sure mine will be covered after I meet my 3500 deductible.  Has anyone ever opted to do it in the drs office without anesthesia?  My dr said he could do that but it wasn’t the norm and I would be uncomfortable.  My insurance despite having a high deductible actually has no copay’s for dr visits or procedures done in office visit.  I’m just wondering how uncomfortable this could be?  I am uncomfortable when I go in for my yearly check and he does that exam.  

For me, going without anesthesia hurt. When a doc says it's going to be uncomfortable, to me it means painful. It was painful, so for all subsequent pouchoscopies I was sedated/anesthetized and was glad of it, even though I had to have someone drive me there and back.

I have done the pouchoscopy with and without sedation (NOT anesthesia or propofol, the use of which is morally, ethically and financially repugnant to me for reasons beyond the scope of this thread). I prefer conscious sedation (which is maybe $200 extra vs. $2000 for propofol) only because when they pump the pouch up with air, like a helium balloon, it's uncomfortable. I prefer to be comfortable. Is it doable without any sedation? Yes. Uncomfortable.  But why torture yourself?????? (Outside of conscious or subconscious sadomasochism). I get a ride and take the conscious sedation.

Also, pouchoscopies usually retail for $1000 to $1500, so I assume the $3500 number is on deductible. You guys are going to have to pay a deductible whether the pouchoscopy is had or not, right? I never heard of anyone with a J Pouch staying under a $3500 deductible. Mine is $5000. So I don't really understand the talk about not having a pouchoscopy because of deductibles.

I think the original poster was hoping to get the pouchoscopy as a screening (like a post age 50 every 10 year screening colonoscopy), and no deductible or copays.

I am on Medicare now, and the reimbursements are crazy low. My university hospital bills like 20k for everything and Medicare allowable for everything is less than 2k

I am the original poster and yes I was hoping to get the pouchoscopy to be viewed by the insurance as a preventative colonoscopy without deductibles or copays since in essence the pouch is my colon.  

i have 3 kids, one just finished college, one on college and another one will be in college next year.  Very expensive … so if I could avoid the 3500 deductible it would be great.  

Thank you to all who took the time to respond.  

When the question of sedation for pouchoscopy has come up here before folks seemed about evenly split between getting sedation or not. I’ve never bothered to get sedation - it’s a quick procedure, and as long as the person inflating the pouch exercises some restraint I’ve not found it to be a difficult procedure. Folks who need dilation or who have very inflamed, tender areas are in a different situation, of course.

@CTBarrister posted:

I have done the pouchoscopy with and without sedation (NOT anesthesia or propofol, the use of which is morally, ethically and financially repugnant to me for reasons beyond the scope of this thread). I prefer conscious sedation (which is maybe $200 extra vs. $2000 for propofol) only because when they pump the pouch up with air, like a helium balloon, it's uncomfortable. I prefer to be comfortable. Is it doable without any sedation? Yes. Uncomfortable.  But why torture yourself?????? (Outside of conscious or subconscious sadomasochism). I get a ride and take the conscious sedation.

Also, pouchoscopies usually retail for $1000 to $1500, so I assume the $3500 number is on deductible. You guys are going to have to pay a deductible whether the pouchoscopy is had or not, right? I never heard of anyone with a J Pouch staying under a $3500 deductible. Mine is $5000. So I don't really understand the talk about not having a pouchoscopy because of deductibles.

I have high premiums... Then i have a high deductible of $6000. it doesnt split to 80/20 until I reach that deductible. So when pouchoscopy is sent to insurance, my out of pocket is just over $3000.. thats why I cant afford to go every year. and I had a pouchoscopy once without sedation and it was VERY uncomfortable but tolerable. But it wasnt that much cheaper as it still had to be done in a procedure room. But thats Cleveland Clinic which is awful. I had 1 PT appt 2 weeks ago and they charged the insurance $933 and i had to pay $553 of that.. for one PT appt. lol.. joke

Poucho- $3000 sounds kind of high for a pouchscopy. I live in Connecticut which has a very high cost of living as compared to elsewhere in the USA and usually it's $1500 max (with sedation). Of course if they take biopsies there could be separate lab charges.

I am lucky my employer pays my health insurance premiums which are over $1,000 a month.

@Pouchomarx posted:

I have high premiums... Then i have a high deductible of $6000. it doesnt split to 80/20 until I reach that deductible. So when pouchoscopy is sent to insurance, my out of pocket is just over $3000.. thats why I cant afford to go every year. and I had a pouchoscopy once without sedation and it was VERY uncomfortable but tolerable. But it wasnt that much cheaper as it still had to be done in a procedure room. But thats Cleveland Clinic which is awful. I had 1 PT appt 2 weeks ago and they charged the insurance $933 and i had to pay $553 of that.. for one PT appt. lol.. joke

Well yes... i have a pouch due to low grade dysplasia and UC but i always have to get biopsies with my scope

https://www.j-pouch.org/topic/...9#713889682402771909 Did Medicare pay for you Pouchoscopy?

Yeah my insurance covered mine. Have the doctor enter the info as a "sigmoid colonoscopy" that will make more sense to the insurance company.

Thank you.