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FACT: All persons 50+ years of age, and
younger patients who have a family history of colorectal cancer,
should receive regular checkups for the disease.
Medicare Benefit for Colorectal Cancer
Screening
Until January, 1998, all leading scientific authorities agreed
that regular screening and early detection could dramatically
reduce the annual death toll from colorectal cancer, but Medicare
had not previously paid for screening tests.
*Since January 1, 1998, all Medicare beneficiaries have been
entitled to regular colorectal cancer screening—Medicare
rules provide reimbursement for the first time! Now as of
July 1, 2001, the Medicare screening benefit has been expanded
to include screening colonoscopy for average risk individuals
once every ten years.
Why is This Important?
Colorectal cancer is the nation’s No. 2 cancer killer,
claiming the lives of 56,000 persons each year, according
to the American Cancer Society.
Why Should You Have Screening Tests Done?
- Screening can prevent cancer by removing precancerous
growths (polyps)**
**Polyps are growths within the colon that occur fairly commonly
as people grow older. While polyps frequently are benign,
they also can be precancerous. If polyps are detected and
removed in their benign, precancerous or early cancerous stages,
deaths and later surgeries can be avoided.
- Early detection diagnoses cancers before they have a
chance to spread
Up to 90% of colorectal cancer deaths can be prevented by
timely removal of precancerous polyps.
What You Need to Know
Congress passed a law in 1997 that directed Medicare to pay
for three tests for colorectal cancer screening which have
been shown to detect polyps and cancers early. In 2000 Congress
passed a law adding an additional benefit. One of the screening
options, screening colonoscopy, is now reimbursable by Medicare
as to high risk patients; screening colonoscopy will be reimbursed
as to all Medicare beneficiaries who receive the test after
July 1, 2001. The law defines a frequency for screening colonoscopy
of no more than once every two years for high risk patients,
and no more frequently than once every 10 years for average
risk patients.
- Fecal occult blood tests — will
be paid for annually (when ordered by the patient’s
attending physician) for all patients;
- Flexible sigmoidoscopy — will
be paid for once every four years for average risk
patients;
- Individuals NOT at high risk — screening
colonoscopy — will be paid for once every
ten years for average risk patients after July 1, 2001;
- Individuals at high risk — screening colonoscopy
— will continue to be covered at once every two
years for high risk patients (see definition below).
The final rule from the U.S. Department of Health and Human
Services (“HHS”) also addresses the possible use
of barium enema X-ray as an alternative to the endoscopic
examinations for some average and high risk patients.
Do You Want to Know More?
ALL COLORECTAL EXAMS WERE NOT CREATED EQUAL
What are My Options?
Here is some information to help you and your doctor pick
the best test for you!
Fecal Occult Blood Tests
The most common and inexpensive colorectal cancer screening
device, FOBT has an important role in colorectal cancer screening.
This test, which can be performed at home and mailed to the
medical lab, involves examining a small sample of stool to
see if any hidden blood, which you would not be able to see,
is present. This test alone is not sufficient for accurate
screening. Studies in the Journal of the American Medical
Association by researchers at the Mayo Clinic found such
stool tests to be only 30% effective in detecting early colorectal
cancer. The test can be positive falsely, due to diet or medications.
While this test is important, it needs to be combined with
one of the other tests explained below.
Everyone—particularly older Americans and patients
with gastrointestinal problems, who usually are among those
with an increased risk of colorectal cancer—should know
as much as possible about screening options available for
colorectal cancer screening.
Here are some alternatives to consider:
Flexible Sigmoidoscopy
PROS: Easy, least expensive and highly accurate
in examining the lower third of the colon.
CONS: Since only one-third or less of the
colon is examined, cancers arising in the upper colon may
go undetected.
MEDICARE STATUS: Available generally without
pre-certification once every four years to Medicare beneficiaries
over age 50.
Colonoscopy
PROS: Most reliable, visualizes entire colon
and offers the capacity to remove many growths and cancers
during the examination.
CONS: Cost, however, the Medicare fee for
this procedure has dropped substantially. While colonoscopy
is very safe, there is a small risk of injury to the colon.
MEDICARE STATUS: AVERAGE RISK: After July
1, 2001, it will be available generally without pre-certification
once every ten years to Medicare beneficiaries over age 50;
or
HIGH RISK INDIVIDUALS: It is available generally without pre-certification
once every two years to Medicare beneficiaries over 50 who
meet the definition of a “high risk patient” (below).
Colonoscopy is also the diagnostic tool used most frequently
if patients have positive results on one of the other colorectal
cancer screening tests.
Barium X-Ray
PROS: Usually examines the entire colon.
Cost.
CONS: Will detect only about half
of large polyps and 75% of early cancers. Smaller cancers
and precancerous lesions may be missed because radiology creates
a “contrast” picture, rather than directly visualizing
the colon; cannot be used to biopsy or remove polyps or tumors.
When the barium enema identifies a polyp, tumor or other abnormality,
a second test, colonoscopy, usually must be performed to confirm
any positive results from a barium enema, to obtain a biopsy
or remove the growth.
MEDICARE STATUS: The final Medicare rule
states that “...while there is not a consensus in
the medical community regarding the specific role of a barium
enema examination under the Medicare colorectal cancer
screening benefit when compared to the use of the flexible
sigmoidoscopy and colonoscopy examinations, there is a sufficient
basis for us to include the use of barium enema as part of
the new national Medicare coverage for colorectal screening”
[emphasis added].
Pre-certification always required—Unlike the endoscopic
tests which can be provided without restriction, HHS states
that in order for a screening barium enema to be reimbursed,
a specific written order is required from the patient’s
attending physician. That written order must consist of
the attending physician’s certification that “...in
the case of this particular individual, that the estimated
screening potential for the barium enema examination is
equal to or greater than the screening potential that
has been estimated for the colonoscopy“ or “flexible
sigmoidoscopy“...“for that same individual”
[emphasis added].
Virtual Colonoscopy
Virtual colonoscopy, also called CT colonography, is an X-ray
test that looks for cancer and precanerous growths, known
as polyps, in the colon (large bowel). Virtual colonoscopy
is based on a CT scan of the abdomen and pelvis. If polyps
are detected, or if virtual colonoscopy is technically indadequate,
conventional colonoscopy is still needed.
Is virtual colonoscopy covered by Medicare or recommended
by experts?
Medicare does not reimburse the costs for virtual colonoscopy
for colon cancer screening. Virtual colonoscopy is not on
the list of procedures recognized by Medicare as appropriate
for colon cancer screening and approved for Medicare payment.
At this time, no expert or national organization, including
the American Cancer Society, has endorsed the use of virtual
colonoscopy for colorectal cancer screening. While there have
been some attempts by experts to evaluate the effectiveness,
costs and benefits of virtual colonoscopy, at this time, there
has been no definitive demonstration to support either its
overall effectiveness or cost-effectiveness.
Are You a High Risk Patient?
Medicare says you are a high risk patient if you have:
- A close relative (sibling, parent, or child) who has had
colorectal cancer or an adenomatous polyp; or
- A family history of familial adenomatous polyposis; or
- A family history of hereditary non-polyposis colorectal
cancer; or
- A personal history of adenomatous polyps; or
- A personal history of colorectal cancer; or
- Inflammatory bowel disease including Crohn’s disease,
or ulcerative colitis.
High risk patients are entitled to colonoscopy every two
(2) years generally without any requirement for any written
certifications by the attending physician. In some instances,
a barium enema may be substituted (see pre-certification requirements
above).
Whom Should I See?
Screening tests are unequal, so the reliability of results
depends on the skills, experience and expertise of the physicians
performing the procedures. All of the above tests involve
examining the colon, which means these tests are only as good
as the physician’s ability and experience.
More experienced physicians will have better skills in using
the instruments—the sigmoidoscope and colonoscope—to
get the best picture possible within the colon, which in turn
promotes more reliable diagnoses. Colonoscopy allows for both
diagnosis and therapy in the course of a single examination.
A large portion of flexible sigmoidoscopies are provided by
family physicians and internists. Colonoscopies are most often
performed by a specialist, a gastroenterologist. If a polyp
is present, the instrument often can be used to remove it
at the time it is detected, eliminating the need for either
a repeat procedure or surgery. Therefore, particularly with
colonoscopy, the more experienced physician is better equipped
to take care of the entire problem “on the spot.”
Since barium enema cannot remove any growths, when a polyp
is found, referral is needed to a gastroenterologist or a
surgeon specializing in diseases of the colon. This requires
a second procedure (to actually remove the growth) for the
30% or so who have a polyp.
The Bottom Line
While it is normal to be anxious about the various screening
tests available, you should rest assured that, under most
circumstances, none is terribly unpleasant. To get the best,
most reliable results, consult your physician about which
exam is right for you, and make certain that your exam is
performed by a physician who has comprehensive training, skills
and expertise.
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