Prostate Specific Antigen (PSA)
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.
Total prostate specific antigen (PSA) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.) (See Applicable Tennessee State Mandate Requirements below.)
Total prostate specific antigen (PSA) is considered medically appropriate if ANY ONE of the following criteria is met:
Individuals age 50 years or older
Individuals under age 50 when determined by a physician to be medically necessary
APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS
The provisions of this mandate concerning early detection of prostate cancer, Tennessee Code Annotated, Title 56, Chapter 7, Part 2354 read as follows:
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.
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
Tennessee Code: Title 56 Insurance. Chapter 7 Policies and Policyholders: Part 23 Mandated Insurer or Plan Coverage, 56-7-2354. Early detection of prostate cancer. Retrieved November 2, 2018 from https://advance.lexis.com/documentpage.
U. S. Preventive Services Task Force. (2018, May). Screening for prostate cancer: U.S. preventive services task force recommendation statement. Retrieved November 2, 2018 from https://www.uspreventiveservicestaskforce.org.
ORIGINAL EFFECTIVE DATE: 7/1995
MOST RECENT REVIEW DATE: 12/13/2018
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.
This document has been classified as public information.