Monday, April 15, 2024

Is A Psa Test Covered By Medicare

Don't Miss

Medicare Coverage For Prostate Specific Antigen Test

Prostate Health and a cancer screening test Medicare

Home / FAQs / Medicare Coverage / Medicare Coverage for Prostate Specific Antigen Test

Medicare will cover prostate-specific antigen tests for those who need it. Prostate cancer is prevalent among men. About one out of every nine men will receive a prostate cancer diagnosis. The blood test is considered a routine screening for beneficiaries. As long as your doctor takes Medicare, you should have coverage.

In conjunction with other testing methods, PSA tests can help screen for cancer at an early stage so you can get the best treatment available. Lets go over what Medicare will cover when it comes to screening for prostate cancer.

Personal Stories About Having A Prostate

These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.

I have two children who are in high school right now, and both plan to go to college. It’s important to me to provide for them and ensure that they have the money they need to finish their education. If I found out I had cancer, I would try any treatment that might offer me a chance to live longer, even if it has side effects. I’m going to have the PSA test.

Eric, age 56

For me, there is still too much uncertainty about how helpful the PSA test is and how accurate it is. I’ve read that high PSAs can be caused by things other than cancer. But the only way to check for cancer is to have a biopsy. I don’t want to have to go through that if I don’t have to. And the fact that I might be treated for a cancer that wouldn’t have caused a problem is troublesome. So for now, I’m not going to have the PSA test.

Mike, age 62

My health is great. I still run, play tennis, and travel a lot. At my age, you start to see friends getting sick and dying of one thing or another, and it makes you start to think about your own health more. I know that the PSA test isn’t perfect, but I want to have every chance I can to treat cancer early if I have it.

Jacob, age 68

Pieter, age 67

What Do The Experts Recommend

Experts have set up guidelines to advise men about prostate cancer screening.

These guidelines are based on a man’s age and his risk of getting prostate cancer. Some things that put men at a higher risk include:

  • Being African American.
  • Having a father or brother who had prostate cancer before age 65.
  • Knowing that a gene change, such as BRCA, runs in your family.

Most experts agree on the following age-related recommendations.

Age 40 and under:

Men aren’t advised to get the PSA test, since testing in this age group causes more harm than good.

Age 40 to 54 years:

  • Men at average risk aren’t advised to get the PSA test, since testing in this age group causes more harm than good.
  • Around age 45, men at higher risk may want to talk with their doctors about the pros and cons of testing before deciding whether to get the PSA test.

Age 55 to 69 years:

Men who are thinking about getting the PSA test are advised to talk with their doctors about the pros and cons of testing before deciding whether to get the PSA test.

Ages 70 and older:

Most men aren’t advised to get the PSA test, since testing in this age group causes more harm than good.

Read Also: Is Dental Care Included In Medicare

What Is The Cost Of A 4kscore Test And Will Insurance Cover It

We often hear from patients and physicians interested in learning more about the cost associated with the 4Kscore test, and whether the test is covered under Medicare, Medicaid or other health insurance plans. This is a confusing area and the answers always vary because of different insurance carriers and plans.

Medical Insurance Coverage For Prostate Cancer

Medicare Covers Annual PSA

Understanding the benefits provided by your medical insurance is critical as you explore the possible tests and treatments for prostateThe prostate is a walnut-sized gland located between the bla… Full DefinitioncancerCancer is a group of diseases where cells grow abnormally an… Full Definition. Whether you have private insurance such as a Health Maintenance Organization , a Preferred Provider Organization , a government-sponsored insurance program like Medicare or Medicaid, insurance from the Health Insurance Marketplace also known as an exchange, or Department of Veterans Affairs Health Benefits , you may want to request a case manager from your provider to help you navigate your coverage. Keep in mind that the type of insurance you have may impact the amount of out-of-pocket costs you pay during treatment and through recovery.

While health insurance covers many of the costs of cancer care, there are other types of insurance that may help pay for other associated expenses. These include Supplemental Insurance, Disability Insurance, Hospital Indemnity Insurance, and Long Term Care Insurance. You may want to speak with your insurance agent about your eligibility for these and other programs.

Read Also: Should I Get Medicare Supplemental Insurance

How Is A Digital Rectal Exam Different From A Prostate

A digital rectal exam is when a doctor inserts his finger into your rectum to feel your prostate for signs of enlargement. A prostate-specific antigen test is a blood test that measures how much PSA is present in your blood. Often, doctors use both digital rectal exams and PSA testing to screen for prostate cancer.

Medicare Advantage And Cancer

If you have Medicare Advantage , this means that youve purchased your Medicare plan from a private insurance company as opposed to getting it directly from the federal government. These types of plans are required to give you the same basic coverages as Original Medicare, but the CMS warns that they can have different rules and costs. Therefore, its important to go through your individual plan so you understand what it says regarding cancer coverage specifically. And if any portion of that policy is unclear, follow up with your policys administrator so you know what is covered and what isnt.

You May Like: Is Obamacare Medicaid Or Medicare

What Do Numbers Tell Us About Benefits And Risks Of Psa Testing

Examples of outcomes with and without PSA testing in men ages 55 to 69*

Prostate cancer deaths in men who were followed over a 13-year period About 6 out of 1,000 men will die of prostate cancer. About 5 out of 1,000 men will die of prostate cancer.
Prostate cancers found in men who were followed over a 13-year period About 68 out of 1,000 men will be diagnosed with prostate cancer. About 102 out of 1,000 men will be diagnosed with prostate cancer.
Risk of receiving treatment you don’t need None About 27 out of 1,000 men may get treatment they don’t need.
High PSA results that are not cancer , *

High PSA results that are not cancer Out of 1,000 PSA tests, about 170 will find a high PSA level. Out of those 170 high PSA test results, about 129 will not be from cancer, while about 41 of the 170 will be from cancer.

These numbers are from the largest, longest study done so far on the value of PSA testing. The study was done in Europe and did not include African-American men, who are at higher risk of prostate cancer.1 A smaller study done in the United States did not find that PSA testing saved lives.3

*Based on the best available evidence


The quality of the evidence about PSA benefits is moderate.

The largest study of prostate cancer screening so far showed that out of a group of 1,000 men ages 55 to 69 who have PSA testing and are followed over a 13-year period :1


The quality of the evidence about PSA risks is high.

Understanding the evidence

If Your Coverage Is Denied Follow These Steps To Appeal Your Case:

Medicare & You: Men’s Health
  • Ask your health plan which guidelines they used to formulate the denial.
  • Submit documentation clearly stating the reason for the requested service. Health plans make their coverage decisions based on the documentation you provide, so its in your best interest to provide complete information up front. Print out any information that supports your position. Keep copies of all medical documentation. In many cases, your physician can provide the medical documentation you need. Your physician can also discuss the denial with your health plans physician reviewer.
  • You can also ask your doctor to appeal to the insurance company directly. Sometimes the insurance company needs very specific medical details to approve a test or treatment.
  • Follow up with your health plan if it hasnt responded in a timely manner.
  • If your appeal is not overturned on the first try, request a second appeal. Most plans also provide a third level of appeal. If all levels of appeal are overturned, consider filing with an independent review board or the insurance commissioner. At this point, you may require a lawyer. Be persistent, factual, and adhere to all requests and requirements of the health plan.
  • While this process may seem like a lot of work, it is absolutely worth it if it means you can choose the care option that is best for you. Work with your doctor to find and fund the best treatment you possibly can.

    Recommended Reading: Does Medicare Coverage Work Overseas

    When Is A Non

    The coverage, and subsequent payment, for a PSA test is determined by the contractual agreement with the patient’s insurance company. Some insurance companies pay and others do not for procedures and other services with different diagnoses.

    Medicare developed a “national payment determination” several years ago that identified a finite number of diagnoses for which they would support payment for a PSA test. “Hypogonadism” was not one of those diagnoses. If the PSA test is ordered with one of the diagnoses, such as cancer of the prostate, elevated PSA level, etc., Medicare will pay for it any number of times that the test is considered to be medically necessary during the year, but they will not pay for a PSA test for any other diagnoses, other than a “screening” test, as discussed below.

    We would recommend that, in addition to appealing the denial, you ask your doctor to write a letter to the AUA asking them to petition Medicare to add hypogonadism to the list of diagnoses to be paid for a non-screening PSA test.

    A. The required pre-authorization is a coverage issue between the patient and his insurance company. You should not spend your time dealing with coverage issues on a prescription drug. That is the patient’s problem. In fact, the difficulty you experience will never be corrected unless the purchaser of the insurance-the patient or his employer-deals with the insurance company directly to correct the “delaying tactics” that the insurance company has implemented.

    Getting What You Want From Obamacare

    Obamacare offers a fabulous array of plans, prices, services and locations in addition to the essential health benefits and legal protections. In such a broad and busy scene, sometimes applicants can lose sight of a few important things such as risks based on personal and family history. Comparison shopping is important for getting the best match for the subscribers needs and preferences. Some procedures may have particular importance to an individual based on family and medical history. When comparing plans, it is useful to consider policies, facilities, and network services given expected needs or past practices. Start comparing health insurance providers now by using our FREE tool below!

    Read Also: What Is A Medicare Discount Card

    Further Tests For Prostate Cancer

    If results of the PSA test or the DRE are abnormal, a urologist will likely recommend a biopsy, where small samples of tissue are removed from the prostate and examined.

    If cancer is diagnosed, other tests may be used to check the progression of the cancer, including:

    • magnetic resonance imaging scan of the prostate – often done before a biopsy
    • bone scan – to check whether or not cancer cells have spread to the bones
    • computed tomography scan – a specialised x-ray
    • pelvic lymph node dissection – a nearby lymph node is removed and examined to check whether or not cancer cells have entered the lymphatic system .

    Whats The Difference Between A Prostate Specific Antigen Test And A Digital Rectal Exam

    Medicare and Prostate Cancer Screening

    While there are many different ways to check for prostate cancer, two remain the most popular. A prostate-specific antigen test is a blood test. The PSA level in the blood may be higher for those who are dealing with prostate-related issues.

    A high level of PSA in the blood can mean a few things, such as:

    • A reaction to certain medications.
    • You may have an enlarged prostate.
    • You may suffer from a prostate infection.

    A digital rectal exam is a physical exam, rather than a simple blood test. Your doctor will check for abnormalities with your prostate, which may indicate cancer. Youll want to ask your doctor beforehand to find out which test may be best for you.

    Don’t Miss: Does Plan N Cover Medicare Deductible

    Where To Get Rezum Water Vapor Therapy For Enlarged Prostate In Nyc

    At New York Urology Specialists, we offer same-day treatment for urinary problems and enlarged prostate men.

    or make an appointment online.

    We perform a cystoscopy, urodynamic testing, prostate and bladder ultrasound in our office. We offer Urolift procedure, Rezum water-vapor procedure in our office and laser enucleation of the prostate in a hospital setting. We treat urinary and erection problems. We offer confidential appointments. We offer affordable appointment prices with or without insurance.

    Dr. Alex Shteynshlyuger is an experienced urologist who has treated hundreds of men with an enlarged prostate. He is one of the few urologists who offers a full range of treatment options for BPH including REZUM procedure, Urolift for BPH, and laser prostate enucleation. is a board-certified urologist, who specializes in all aspects of care for urinary problems in men including BPH, frequent urination, slow urine stream, enlarged prostate, and urinary tract infections.

    Also Check: Cranberry Juice And Prostate

    The Essential Health Benefits

    Screenings and preventive care are among the important ten essential health benefits found in every qualified health plan. The use of more patient based decisions and detection techniques was not affected by the recommendation against PSA testing. Obamacare provides no cost procedures that primary care physicians use to detect prostate disease. They particularly include the following that relate to cancer detection.

    • Immunizations and screenings
    • Wellness

    Read Also: When Am I Available For Medicare

    When Does Medicare Cover The Psa Test

    All men over 50 are eligible to receive a free PSA test once every 12 months under the preventive services benefits included in Medicare Part B. If your doctor accepts Medicare assignment, you pay nothing. If your doctor does not accept Medicare assignment, you may pay a fee for the doctor services, but not for the PSA test itself.

    How Often Will Medicare Pay For A Psa Test What’s Covered App Demo

    Medicare Part B pays for one prostate cancer screening test each year. You pay no out-of-pocket cost for a PSA test if your doctor accepts Medicare assignment, and the Part B deductible does not apply.

    Medicare Advantage plans also cover a yearly PSA test. Check with your plan for coverage details.

    Talk with your doctor about prostate cancer screening. You may hear different ideas about how often men need to have a PSA test so its important for you and your doctor to decide whats best for you.

    You May Like: How To Get Medicare To Pay For Hearing Aids

    Will Medicare Cover Prostate Specific Antigen Tests

    Medicare Advantage policies must cover a minimum of what Medicare will cover. What exactly does this mean for you? While youll get a routine PSA test at no charge to you, there may be extra fees.

    If your doctors decide he wants to run follow-up tests, you wont need to pay for these. Instead, your Medicare Advantage policy will pay for screenings. Remember that Medicare advantage plans run within a network. Your provider and the facility you get treatment in will have to be in your network. If not, youll undoubtedly have high medical bills to pay.

    State Efforts To Ensure Prostate Cancer Screening Coverage

    States have passed laws on a variety of issues relating to prostate cancer, including:

    • Assured health insurance coverage for prostate cancer screening
    • Public education on prostate cancer
    • Prostate cancer research funds

    Many states have laws requiring private health insurers to cover tests to detect prostate cancer, including the PSA test and digital rectal exam . Some states also assure that public employee benefit health plans provide coverage for prostate cancer screening tests. Most state laws assure annual coverage for men ages 50 and over and for high-risk men, ages 40 and over. “High-risk men” typically refers to African-American men and/or men with a family history of prostate cancer. Some states have slightly different coverage requirements.

    Laws on coverage vary from state to state, so check with your insurer or with your state insurance commissioners office to see whats covered.

    Also Check: How To Apply For Medicare Insurance

    Will Medicare Advantage Cover Prostate Specific Antigen Tests

    Medicare Advantage policies must cover a minimum of what Medicare will cover. What exactly does this mean for you? While youll get a routine PSA test at no charge, there may be extra fees. If your doctor decides they want to run follow-up tests, you wont need to pay. Instead, your Medicare Advantage policy will pay for screenings. Remember that Medicare advantage plans run within a network. Your provider and the facility where you get treatment will have to be in your network. If not, youll undoubtedly have high medical bills to pay.

    More articles

    Popular Articles