Just Saying "No" to Colonoscopy

Just when you thought you'd heard it all; just when you thought you'd heard every unbelievable, incomprehensible, illogical policy* imaginable; just when you thought it was safe to champion preventive care, comes the Darwin Award for the lowest an insurance company can go.

There's this patient whose father, sister and aunt all had colon cancer in their 40's, so you recommend a screening colonoscopy. The patient is perfectly willing to go (only about 1 in 10 patients right there!) but is told by her insurance company that they don't cover screening colonoscopies.

That sucks, especially since the company prides itself on its comprehensive preventive care that covers annual mammograms over 40 (shown to cause more harm than good, when anxiety from false positives is factored in) and PSAs for men over 50 (never shown to lengthen life). Still, patients often have symptoms like fatigue and changes in bowel habits, which allow the procedure to be coded as a diagnostic colonscopy instead of a screening one.

Ready for the kicker?

This company won't cover diagnostic colonoscopies either.

Epic WTF?

Let me get this straight: whatever the symptom, whatever the history, whatever the possible diagnoses, under no circumstances will this particular company ever cover the specific non-invasive procedure known as colonoscopy?

Yep.

How can they do this? By including this language in their "Plan Exclusions":

Colonscopy both screening and diagnostic is considered a non-covered service under this plan. This test may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this procedure is the most appropriate choice for their situation, they are encouraged to proceed with the procedure at their own expense.

Apparently, this is how the insurer transfers liability for non-coverage; it seems that this is permitted under the Supreme Court decision handed down in regards to insurer liability for non-coverage of an accepted level of care.

It turns out that this is considered purely a cost-containment measure.

What the hell next? There are plenty of other ways to save significant sums of money:

• CT scanning is considered a non-covered service under this plan. This test may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this test is the most appropriate choice for their situation, they are encouraged to proceed with the test at their own expense.
• Levaquin is considered a non-covered therapy under this plan. This drug may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this drug is the most appropriate choice for their situation, they are encouraged to receive this drug at their own expense. [Not all that bad an idea, actually. In addition to being hideously expensive, it's rarely the best choice.]
• Chemotherapy is considered a non-covered treatment under this plan. This treatment may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this treatment is the most appropriate choice for their situation, they are encouraged to receive this treatment at their own expense.

It seems that in order to effectively contain costs, insurance companies are moving away from actually paying for medical care. And this is the private insurance that "most Americans are happy with"?

Un-fucking-believable.

h/t to BS


* Aside from Medicare paying for kidney transplants, but discontinuing coverage for anti-rejection drugs after three years.