Does Medicare Cover an Upper Endoscopy?

An upper endoscopy is a medical procedure used to examine the upper part of the digestive system, including the esophagus, stomach, and the beginning of the small intestine. This common diagnostic tool helps healthcare providers investigate symptoms such as persistent heartburn, difficulty swallowing, or unexplained abdominal pain. Understanding how Medicare covers this procedure is important for beneficiaries to manage potential costs and ensure access to necessary medical care.

Medicare Coverage for Upper Endoscopy

Medicare covers an upper endoscopy when a healthcare professional determines it is medically necessary to diagnose or treat various health conditions. This procedure is covered under Medicare Part B, which is medical insurance for outpatient services. Medicare Part B covers 80% of the Medicare-approved amount for medically necessary upper endoscopies after the annual deductible is met.

Medical necessity means the procedure is performed to investigate symptoms such as persistent heartburn, difficulty swallowing (dysphagia), unexplained weight loss, or gastrointestinal bleeding. For example, if a doctor suspects an ulcer, inflammation, or a growth, an endoscopy can provide direct visualization and allow for tissue biopsies. While diagnostic endoscopies are covered, routine screening endoscopies are not covered unless specific risk factors or symptoms are present, or if it’s part of a covered diagnostic workup. If an endoscopy leads to an inpatient hospital stay, Medicare Part A (Hospital Insurance) might apply for the hospital portion of care, though the procedure itself is usually outpatient.

Medicare Advantage Plans, also known as Part C, are required to cover at least the same services as Original Medicare (Parts A and B). However, these plans may have different rules regarding network providers, referrals, and cost-sharing structures. Beneficiaries with a Medicare Advantage Plan should consult their specific plan details to understand their coverage for an upper endoscopy.

Your Out-of-Pocket Costs

Under Original Medicare, your financial responsibility for an upper endoscopy involves a deductible and coinsurance. For 2025, the annual Medicare Part B deductible is $257. You are responsible for paying this deductible amount before Medicare begins to pay its share of covered services. After meeting the deductible, you pay a 20% coinsurance of the Medicare-approved amount for the procedure, while Medicare Part B covers the remaining 80%.

These out-of-pocket costs can include fees for the facility where the endoscopy is performed, such as an ambulatory surgical center or hospital outpatient department, and the physician’s professional fees. Medigap (Medicare Supplement Insurance) plans can help cover these out-of-pocket expenses, such as the Part B coinsurance.

Medicare Advantage Plans have different cost-sharing rules, which may include copayments or coinsurance amounts for services like an endoscopy. These plans also include an annual maximum out-of-pocket limit for covered services under Parts A and B. Once this limit is reached, the plan pays 100% of covered services for the remainder of the year.

Ensuring Coverage and Next Steps

To ensure your upper endoscopy is covered, the procedure must be ordered by a doctor and documented as medically necessary. Your healthcare provider’s office will handle the necessary paperwork and coding to reflect the medical reason for the endoscopy. Before scheduling the procedure, confirm with your provider and your Medicare plan about any prior authorization requirements, particularly for non-emergency procedures.

Verifying that both the facility and the performing physicians are Medicare-approved or are within your Medicare Advantage plan’s network is also important. Using out-of-network providers with a Medicare Advantage plan can result in significantly higher costs or no coverage at all. If there is a possibility that Medicare might not cover a service, your provider should present you with an Advance Beneficiary Notice of Noncoverage (ABN). This document informs you that Medicare may not pay for the service and that you would be responsible for the cost if Medicare denies the claim.

Should a claim for your upper endoscopy be denied, you have the right to appeal the decision. The appeals process involves several levels, beginning with a redetermination by Medicare. Understanding these steps and gathering all relevant medical documentation is important in pursuing a successful appeal.