Does Medicare Cover a Prostate Biopsy and Cancer Screening?
Key Takeaways
- Prostate screenings, including a prostate biopsy, can be effective tools in identifying cancer in a timely fashion so you can be treated.
- Medicare generally covers a prostate biopsy if it’s medically necessary.
- Typically, a PSA blood test or a digital rectal exam — also covered by Medicare — would be performed before a prostate biopsy to determine if there is a need.
- Medicare Part BMedicare Part B is medical insurance that covers Medicare-approved services — such as medically necessary treatment and preventive services — and certain other costs, like durable medical equipment. Medicare Part B is part of Original Medicare. will pay 100% of the cost of an annual PSA test after age 50 and will cover 80% of the costs for a digital rectal exam and prostate biopsy after you pay your annual deductibleA deductible is an amount you pay out of pocket before your insurance company covers its portion of your medical bills. For example: If your deductible is $1,000, your insurance company will not cover any costs until you pay the first $1,000 yourself. .
While one in eight men will be diagnosed with prostate cancer in their lifetime, the survival rate is high. If a screening shows cause for concern, Medicare generally will cover a prostate biopsy. During a prostate biopsy, the doctor or provider collects tissue to check for cancer cells or other health concerns.
What Medicare coverage is right for my specific situation?
Find The Right Plan
Does Medicare Cover Prostate Biopsy?
The prostate is a gland in the male reproductive system shaped and sized like a walnut. Medicare covers medically necessaryHealthcare services that are necessary for the diagnosis or treatment of an illness, injury, condition, disease or symptoms.
prostate biopsies. The procedure usually is covered by Medicare Part B, the part of Medicare that covers outpatient procedures.
If you have Part B or have switched from Original Medicare (Parts A and B)Original Medicare is a fee-for-service health insurance program available to Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance).
to a Medicare AdvantageMedicare Advantage (Medicare Part C) is health insurance for Americans aged 65 and older that blends Medicare benefits with private health insurance. This typically includes a bundle of Original Medicare (Parts A and B) and Medicare Prescription Drug Plan (Part D).
plan, you may qualify for a Medicare prostate biopsy.
Is an MRI-guided prostate biopsy covered?
If you have researched prostate biopsies, you may be wondering, “Does Medicare cover MRI-guided prostate biopsy?” The answer is yes.
Also called a fusion biopsy, an MRI-guided prostate biopsy is a procedure that takes the prostate biopsy to the next level in terms of effectiveness. The biopsy uses a combination of MRI images and ultrasound to render a three-dimensional view of your prostate to collect potentially cancerous tissue.
It also is an outpatient procedure and therefore covered by Part B.
How Much Does Medicare Pay for Prostate Cancer Screening?
You may find yourself in need of a prostate biopsy if a preventive prostate screening identifies a cause for concern.
Medicare covers an annual prostate-specific antigen (PSA) blood test and an annual digital rectal exam for men 50 and older.
- If one of those tests makes a prostate biopsy medically necessary, then Medicare Part B will cover it.
- As is the case with many medical services, Medicare Part B will pay 80% of the cost of a prostate biopsy after you pay your annual deductible. You also are responsible for 20% coinsuranceCoinsurance is the percentage of your medical costs that you pay after you meet your deductible. Your insurance company pays the remaining amount. For example: If you have a $1,000 medical bill and your coinsurance is 20%, you’ll pay $200. Your insurance company will cover the final $800. .
Start your Medicare PlanFit CheckUp today.
Call Today
Will Medicare Pay for a Free PSA Test?
Often the first step and the least invasive of the test, one PSA blood test is 100% covered by Medicare Part B every 12 months if you’re at least 50 years old. Another common annual prostate test, the digital rectal exam, is covered the same way most Part B claims are (you pay your deductible and 20%).
Does Medicare cover 4K prostate test?
In 2019, Medicare first wrote a Local Coverage Determination spelling out situations where a 4kscore test may be covered.
The 4kscore test is a blood test that goes beyond the PSA test and may be approved by Medicare if you have moderately elevated PSA levels and meet the other qualifications detailed by Medicare. A 4kscore test could help your doctor determine whether you need a prostate biopsy.
If approved, it’s covered by Part B with responsibility for the annual deductible and 20% coinsurance on you.
How is Prostate Cancer Screening Done?
The PSA blood test (covered once a year by Medicare at no charge) and the digital rectal exam (covered once a year with typical Part B charges) are the initial screenings that help regularly determine if you should be further examined for prostate cancer.
- PSA blood test: A small amount of blood is drawn and sent to the lab for analysis.
- Digital rectal exam: A doctor inserts a lubricated, gloved finger into the rectum.
What is the best screening for prostate cancer?
Opinions vary on the single-best screening tool, but the key is to make sure that you stay on top of getting screened to improve your chances of catching a problem early.
What Age Should You Have a Prostate Exam?
There’s also no consensus on the optimal age for the testing, but opinions generally align with Medicare’s coverage of screenings beginning at the age of 50:
- The U.S. Preventive Task Force recommends PSA blood tests between the ages of 55 and 69.
- The American Cancer Society recommends a PSA test and possibly a digital rectal exam at age 50 for those at average risk, at 45 for those at higher risk, and 40 for those at an even higher risk.
- The American College of Physicians suggests that men age 50 to 69 discuss the pros and cons of prostate screenings with their doctors.
Find the Medicare Plan that works for you.
Find My Ideal Plan
Sources
- Cancer Stat Facts: Prostate Cancer. Cancer.gov.
- NCI Dictionaries. Cancer.gov.
- Prostate cancer screenings. Medicare.gov.
- Local Coverage Determination (LCD): 4Kscore Test Algorithm. CMS.gov.
- Should I Get Screened for Prostate Cancer? CDC.gov.
- American Cancer Society Recommendations for Prostate Cancer Early Detection. Cancer.org.
- American College of Physicians releases new prostate cancer screening guidance statement. ACPOnline.org.
This website is operated by GoHealth, LLC., a licensed health insurance company. The website and its contents are for informational and educational purposes; helping people understand Medicare in a simple way. The purpose of this website is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Our mission is to help every American get better health insurance and save money.
Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.