Your screening was supposed to be free. Why is there a bill?
You scheduled a preventive screening — colonoscopy, mammogram, well-woman exam, cardiovascular screening. The provider told you it was 100% covered. Then they found something during the procedure (a polyp, a suspicious mass) and the claim came back recoded as diagnostic. Now you owe thousands. Federal law often says you shouldn't.
What the ACA actually requires
The Affordable Care Act §2713 requires non-grandfathered plans to cover preventive services rated A or B by the U.S. Preventive Services Task Force at zero cost-sharing. That means no copay, no deductible, no coinsurance. The list includes screening colonoscopies, screening mammograms, cervical cancer screening, and many more.
Critically: federal guidance (FAQ Part XII, Affordable Care Act Implementation FAQs Part 26, and IRS Notice 2004-50) clarifies that a screening colonoscopy that becomes therapeutic because a polyp is removed during the procedure is still preventive. The polyp removal does not convert the visit into a diagnostic procedure for cost-sharing purposes.
What an appeal needs to say
- 1. Document the screening intent. The appeal must establish that the original order, the scheduling, and the patient's reason for going in were all screening — not diagnostic. The order from your doctor, the referral, and your call to schedule are the evidence.
- 2. Cite ACA §2713 and the federal FAQs. Especially Implementation FAQ Part 26 (Q&A 5), which addresses polyp removal during screening colonoscopy directly. Most denials never engage with this — the appeal forces the reviewer to.
- 3. Ask for the modifier 33 fix. CPT modifier 33 ("Preventive Services") signals to the payer that the service was preventive even if the code suggests otherwise. Often the appeal is really a coding-correction request: re-bill with modifier 33 and the cost-sharing goes to zero. The provider's billing office can usually do this on their end, but the patient often has to push.
Which screenings are covered?
Cost-sharing-free preventive coverage includes (non-exhaustive):
- Screening colonoscopy (and the polyp removal during it)
- Screening mammogram
- Cervical cancer screening (Pap, HPV)
- Well-woman visits
- Cardiovascular disease screening (statin, BP, cholesterol)
- Diabetes screening (USPSTF criteria)
- Counseling for tobacco, alcohol, depression, obesity
- Immunizations on the ACIP schedule
Start your appeal
Upload the bill, the EOB, and the order or referral that scheduled the screening. We draft the appeal letter citing ACA §2713, the federal FAQs, and the request for modifier-33 correction.
Start the appeal →Regulatory references: ACA §2713 (preventive services without cost-sharing); 45 CFR §147.130 (implementing regulation); Affordable Care Act Implementation FAQ Part 26 (screening colonoscopy with polyp removal); CPT modifier 33 (preventive services indicator).
DenialHelp doesn't provide legal advice. Grandfathered plans (rare today) are not subject to §2713 and may legitimately charge for preventive services.