Looking for help with preventative colonoscopy screening

[u/Subject_Narwhal_6072]

So I visited my PCP looking for a referral due to an extensive family history of Colon Cancer (both of my parents were screened and had polyps removed, my Paternal aunt was diagnosed with stage 3 colon cancer at age 40 and died shortly after. Other paternal aunt had polyps removed too. So I pushed my doctor with this information to give a referral for a preventative screening colonoscopy at an earlier age. Was referred to the GI place and did a consultation there. I was able to get a pre auth from insurance but it was mis-coded as a Diagnostic. I was hoping that due to my family history that I could get this as a preventative screening so I could have peace of mind. A friend of my girlfriend's had recently passed away from surprise colon cancer too in her early 40s so I was extremely on edge. I could use any advice or help with writing a letter to my PCP and the GI Doc to help get this coded as a preventative screen even though I am only 36, I feel like I am a high-risk individual due to my familiy history.

Any help would be appreciated with how I can write a letter or what I can say to help my case in getting this coded correctly for insurance. Thanks!

[u/Mountain-Arm6558951]

Writing a letter to your PCP would do no good as that is not the provider who did the procedure.

Most carriers use the United States Preventive Services Task Force guidelines for individuals at risk of colorectal cancer begin screening at age 45. Under 45 would be consider a diagnostic.

Adults aged 45 to 49 years

The USPSTF recommends screening for colorectal cancer in adults aged 45 to 49 years.

Source

https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening

I would recommend checking your carriers medical guidelines on preventative colonoscopes.

[u/Every_Tangerine_5412]

Being high risk makes this a diagnostic study.

[u/EmZee2022 → u/Every_Tangerine_5412]

Exactly.

If you. are under 45, you're unlikely to get it covered as preventive. It'll be covered by informed insurance but subject to deductible and copay.

[u/ReasonKlutzy5364 → u/Every_Tangerine_5412]

Nailed it!

[u/throwawayeverynight]

See it as this,your peace of mind comes with a dollar amount…. If you ask me well worth it specially if nothing was found. The Dr coded it correctly.

[u/positivelycat]

Like other said it is coded correctly codeing criteria dictates digonstic colonoscopy .

Does it suck yes, but it is correct

[u/Trolleyes84]

Being that you have a family history (first generation) of colon cancer, this would be a diagnostic. A preventative is only done when you are of age and no risk factors.

[u/chaos_monster89 → u/Trolleyes84]

It's first degree relative which is parents, sibling or child, so he does not have first degree family history of colon cancer.

[u/Trolleyes84 → u/chaos_monster89]

You are correct. I read this way too late at night and misread.

[u/brettalana → u/Trolleyes84]

I don’t even think this would be considered a family history being that it isn’t first generation.

[u/Alive-Plankton6022]

This is considered diagnostic, nothing to change here

[u/Tardislass]

Sorry. I had a history of colon cancer in my family it still wasn't considered preventative until 45 years old. If you want the test it will have to be diagnostic.

[u/EasyQuarter1690]

I have a family history as well, colon cancer killed my father and grandmother. I have been having colonoscopies for 14 years now and every one of them is diagnostic due to my family history. Screening is different and not for those of us who are at risk.

[u/twisted_german]

Did they remove any polyps or find anything else they had to biopsy? I would go to the GI and ask them why they coded it it as diagnostic and see if it could be resubmitted. I have a family history, and had one at 49 which was under the recommended age at that time, and I got preauthorization and it was covered.  But it was completely normal and I didn't have any biopsies or anything like that.

If you don't doesn’t have any gastrointestinal symptoms and they didn't find any polyps or other abnormality, colonoscopy is considered preventive screening.  That's literally the definition of screening. It doesn't matter if you are at increased risk, as long as you yourself haven't been diagnosed with anything yet and don't have any symptoms.  However, insurance companies have to pay for screening that follows USPSTF recommendations, and they really don't address people under age 45. So even if it is coded like a screening, they may not pay for it, but it's worth a shot.

[u/chaos_monster89]

Take this as you will. I would advise that you look up colon cancer screening guidelines. You have a remote family history of a not first degree relative with cancer. Up to 40% of the US population can have polyps, having family history of polyps is not a guideline for early screening. You absolutely do not have a strong family history of colon cancer and will not meet the criteria for early screening. It sounds like you have a fair amount of health anxiety which you should probably look into for your own sake to prevent yourself from putting yourself through unneeded testing. That being said if you really want to go ahead with it, just tell them you're having rectal bleeding, that usually does the trick. Please keep in mind that the more people who schedule tests like these against guidelines and doctor's advise - the less resources are available for people who actually need it. Aka someone who might actually have colon cancer.

Source - a doctor