BlueCross BlueShield of Tennessee Medical Policy Manual

Prostate Specific Antigen (PSA)

Does not apply to BlueCare.


The prostate specific antigen (PSA) test measures serum levels of the prostate cancer-associated antigen. The test is used to monitor for progression or regression of prostate cancer after therapy. Although increased serum PSA can be an early indicator of prostate cancer, other conditions such as benign prostatic hypertrophy (BPH) can also cause an elevation in the serum PSA level. Measurement of different molecular forms of PSA (free or protein-bound) can increase specificity of the PSA test.

The percent free PSA test measures the free-to-total PSA ration and is intended for use in conjunction with the total PSA test (i.e., VIDAS TOTAL PSA) to aid in distinguishing between prostate cancer and benign prostate conditions. Percent free PSA is significantly lower in individuals who have prostate cancer; therefore, this test is intended to improve the clinical usefulness of the PSA test for detecting early prostate cancer, while decreasing the number of unnecessary prostate biopsies.




This medical policy does not apply to BlueCare.


Compliant with Tenn. Code Ann. § 56-7-2354 (2016)

56-7-2354. Early detection of prostate cancer.

(a) Every contract that provides for hospital, surgical or medical care shall provide, upon the recommendation of a physician, coverage for the early detection of prostate cancer for men fifty (50) years of age and older and other men if a physician determines that early detection for prostate cancer is medically necessary. Nothing contained in this section shall be construed as applying to medical assistance programs funded with state and federal funds, if the programs require the provision of services as medically necessary.


American Cancer Society. (2017) Recommendations for prostate cancer early detection. Retrieved July 12, 2017 from

American College of Physicians. (2013, May) Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians. Retrieved January 8, 2016 from the National Guideline Clearinghouse (NCG: 009823).

Center for Medicare and Medicaid Services. (NCD) for prostate specific antigen (190.31) Retrieved January 8, 2016 from

National Comprehensive Cancer Network. (2017, June). NCCN clinical practice guidelines in oncology™. Prostate cancer early detection (V.1.2017) Retrieved July 12, 2017 from the National Comprehensive Cancer Network.

Tennessee Code: Title 56 Insurance. Chapter 7 Policies and Policyholders: Part 23 Mandated Insurer or Plan Coverage, 56-7-2354. 2015. Early detection of prostate cancer. Retrieved July 12, 2017 from

U. S. Food and Drug Administration. (2004, February). Center for Devices and Radiological Health. Pre-market approval P980007. Retrieved February 7, 2012 from

U. S. Food and Drug Administration. (2004, February). Center for Devices and Radiological Health. Pre-market approval P040008. Retrieved January 8, 2016 from

U. S. Preventive Services Task Force. (2012, May). Screening for Prostate Cancer: U.S. Preventive Services TaskForce recommendation statement. Retrieved July 12, 2017 from




Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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