I am appealing a decision by United Healtcare to not cover the cost of my most recent pouchoscopy. I am really annoyed because UHC covers 100% of a preventative colonoscopy but somehow, this is different.. How is my preventative, routine pouchoscopy any different? I am told no code exists for a pouchoscopy and they can't refer to it as a colonoscopy so it gets coded as an endoscopy & UHC isn't paying for an endoscopy. I have never appealed a decision before but it just occurred to me that I don;t think any insurance has ever covered a pouchoscopy for me. That's not right!!! Just curious, do other pouchers get their pouchoscopies paid for 100%?
Replies sorted oldest to newest
It's usually better to code it as a sigmoidoscopy, which is (like pouchoscopy) preventive care. I've never had a problem with coverage.
Mine is scheduled as a sigmoidoscopy and I am charged an office copay + a lab copay (for the biopsies). If I had sedation, it would be considered an outpatient surgery procedure with a higher copay. But, I have Kaiser and anything that is done by Kaiser providers is covered without preapproval.
Maybe you can talk to your doctor or plan administrator and find out how your past scopes were coded for billing.
Jan 
the whole system of coding was recently changed in theory to create more specificity. to be candid i have no idea how mine are coded but i have 4 dilation pouchoscopys annually and they are always paid for. well to the extent that insurance pays for them until they've sucked my max out of pocket from me and then its FREE! woo hoo. what a crazy system we have, yes still today regardless of all the claims to the contrary ie we fixed healthcare...but i digress. sorry.
definitely appeal!
When I am having cuffitis or pouchitis, the payment is much higher. Hint, hint.
Our *diagnosis* coding system changed a lot in the Fall. Our *procedure* coding system (at least the one that everyone uses) didn't change at all.
My pouchoscopy is called flexible sigmoidoscopy and my insurances pay for it.