That is not a question I want to hear from my doctor, because my response would be something like: “Are you #$%@ing kidding me?” But lately some insurers and physicians have been asking whether colonoscopy sedation is medically necessary; raising questions about whether the patient would need to decide between skipping the sedation or paying for it himself.
Thankfully, recent guidance under the Affordable Care Act (the “ACA”) has reduced the likelihood of being faced with that decision. The ACA requires that health plans (other than grandfathered plans) must pay 100% of the cost of preventive services with no cost sharing to the plan participant. A routine colonoscopy for cancer screening after age 50 is treated as a preventive service for this purpose. But prior to last week there has been no guidance on whether the anesthesia associated with the colonoscopy was part of the services to be fully paid by the health plan.
The guidance was issued by HHS, and it provides that a health plan, “may not impose cost sharing to anesthesia services performed in connection with the preventive colonoscopy.” The guidance leaves open the possibility that anesthesia may not be fully paid if associated with a colonoscopy that is not preventive, such as to remove known polyps. In that case, to save money some patients could decide to opt for civil-war medicine - a shot of whiskey and a leather belt to bite down on.