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Does Medicare Cover a PSA Test?

Medicare will cover a PSA test for men over the age of 50 and for those under 50 years old in certain situations. You’ll receive Medicare coverage if your doctor deems the test medically necessary.

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Medicare will cover prostate-specific antigen tests (PSA tests) for those who need them. Prostate cancer is prevalent among men, with nearly one out of every nine men receiving a prostate cancer diagnosis. The PSA test is a blood test considered to be routine screening for Medicare beneficiaries.

As long as your doctor takes Original Medicare (Medicare Part A and Part B), you are above the age of 50, and your test is necessary according to your healthcare provider, 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. PSA tests measure how much prostate-specific antigen is in your blood, which is a protein created by tissue in the prostate. These tissues can be cancerous and noncancerous by nature.

Remember, having a vasectomy does not increase your risk for prostate cancer. A PSA test falls under your Medicare Part B benefits, and since the screening is preventive, you won’t pay coinsurance or deductibles.

Let’s go over what Medicare guidelines for PSA testing are, how your benefits cover prostate surgery, benefits for similar healthcare screenings, the costs you can expect, and more.

Does Medicare Cover Prostate Surgery?

Yes, Medicare will cover prostate surgery if your doctor decides it’s necessary, as well as other necessary procedures for treating cancer. Any inpatient surgery falls under your Medicare Part A benefits. Outpatient surgical procedures fall under your Medicare Part B.

Keep in mind you’ll pay a portion of the costs, as Original Medicare benefits don’t always cover all of your costs:

Medicare Part A

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Part A will provide benefits, but the amount of coverage you receive depends on your time in the hospital and your lifetime reserve days. The general rule here is that the longer you remain in the hospital, the more you can expect to pay. However, most prostate surgeries only require one night at most, and copayments for your Part A benefits don’t begin until after day 60.

Medicare Part B

Through Medicare Part B, your benefits will cover 80% of your healthcare costs, leaving the remaining 20% up to you. There are additional Medicare options, including Medicare Advantage plans or Medicare Supplement plans (Medigap), that can help you cover these costs. Medigap plans, specifically, pick up where Original Medicare lets up and can cover most, if not all, of the remaining 20% depending on your plan’s benefits.

What Diagnosis Covers PSA for Medicare?

The main focus of a PSA test is to check for signs of cancer. But there may be other diagnoses or concerns that your healthcare provider may wish to look for when conducting a PSA test.

Ultimately, Medicare PSA coverage relies less on the actual diagnosis and solely on whether or not your doctor deems the procedure medically necessary. This is assuming, of course, that you are undergoing the test outside of the Medicare guidelines for PSA testing previously listed.

That said, it’s clear that some concerns or diagnoses will produce a medically necessary designation more often than others. For example, the suspicion of cancer, or diagnosis of the disease, will be more likely to cause your healthcare provider to reach such a conclusion as opposed to less serious reasons.

How Often Will Medicare Pay for a PSA Test?

Medicare Part B will cover prostate-specific antigen tests once every 12 months. Beginning on their 50th birthday, those eligible can have Medicare cover annual PSA tests without being responsible for any charges because it’s preventive care.

There are times in which your Medicare benefits may cover a PSA test outside of this annual test, but it will depend on whether or not your healthcare provider deems the tests medically necessary.

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This may include follow-up screenings or any other testing that is needed. Otherwise, patients that elect to have another test performed will need to pay for the cost out of their own pockets.

How Much do Prostate Specific Antigen Tests Cost?

According to GoodRx, the cost of a PSA test can range from under $100 to more than $300 if you don’t have insurance. But there are other factors that may affect how much you are charred, including the level of care you require after your initial screening.

You may need follow-up visits and screenings to further check for cancer. So, while your initial screen is free, it’s best to prepare for extra charges in the future.

With Original Medicare coverage, your benefits will help you cover the costs of any medically necessary PSA tests, but there may be leftover costs following your Part B coverage. Medicare Supplement plans, also known as Medigap plans, can provide supplemental coverage that picks up these expenses rather than having you pay out of pocket.

Does Medicare Cover PSA and Digital Rectal Exam?

Yes, Medicare benefits will cover both a PSA test as well as a digital rectal exam. While there are many different ways to check for prostate cancer, these two methods remain the most popular:

Prostate-Specific Antigen Test

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.

Digital Rectal Exam

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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. You’ll want to ask your doctor beforehand to determine which test may be best for you.

Does Medicare Cover Prostate Biopsy?

Yes, under normal circumstances, Medicare Part B benefits cover prostate biopsies for diagnostic purposes. Your doctor must state that a biopsy is medically necessary, and your doctor must accept Medicare to use your benefits. A Medicare Advantage or Medigap policy may also provide coverage for prostate biopsies.

Is PSA Total Covered by Medicare?

Finding your PSA total is done by a PSA test. Therefore, the blood test for a PSA test will provide these results, and the same coverage standards remain. PSA Medicare screen coverage for people 50 years of age and older is available, and additional tests are also covered if a healthcare provider deems it to be medically necessary for you as a patient.

Why Is My PSA Test Not Covered by Medicare?

The most common reason for a PSA test not being covered by Medicare is that the test is not deemed medically necessary. Medicare won’t pay outside of annual screening unless your doctor deems the PSA test medically necessary.

This rule of thumb doesn’t just apply to the Medicare guidelines for PSA testing but applies to all healthcare services. Elective procedures or any healthcare services that aren’t declared medically necessary by your healthcare provider aren’t covered by Medicare benefits.

It’s also important to remember a Medicare-denied PSA test may be the result of your age. Remember, annual screenings are a part of preventative care but are not covered for people ages 49 and under. The exception to having Medicare cover a PSA test under the age of 50, of course, is if the test is deemed medically necessary.

Medicare Advantage 4K PSA Test Coverage

PSA Medicare coverage helps beneficiaries, but for those looking for additional coverage, Medicare Advantage policies are available. But a 4K PSA test looks at four proteins, including your free PSA, total PSA, intact PSA, and kallikrein.

While Medicare Advantage policies must cover a minimum of what Medicare will cover, a 4K PSA test is usually not deemed medically necessary and, therefore, not covered by Original Medicare nor an Advantage plan.

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So, while you can receive a routine PSA test at no charge to you if it fits the guidelines listed above, a 4K PSA test is unlikely to be covered. The exception, however, would be if your healthcare provider determines that such testing would be medically necessary for your condition.

But even with Medicare and PSA test coverage, there may be extra fees. This is why Medicare Advantage may be an excellent option for your healthcare needs. If your doctor decides he wants to run follow-up tests, you won’t need to pay for these. Instead, your Medicare Advantage policy will pay for screenings.

Remember, Medicare Advantage plans run within a network. Your provider and the facility you receive treatment will have to be in your network. If not, you’ll undoubtedly have high medical bills to pay.

Conversely, there are other supplemental options available through Medigap policies. Depending on your healthcare, a Medicare Supplement plan may work better for your coverage, and there is more freedom as there are no networks.

How Do Medigap Plans Cover PSA Tests?

Because your Medicare Part A and B benefits only cover 80% of the costs of all prostate cancer-related treatments, without additional coverage, you may end up paying for the remaining 20% out of pocket. By enrolling in a Medicare Supplement plan, you can save on costs as your Medigap benefits will cover the remaining 20%.

Both Medicare Advantage and Medigap plans come from private insurance carriers rather than the federal government, which provides Original Medicare. There are 12 lettered plans for Medicare Supplement plans, and while the benefits are standardized within each letter among carriers, premiums can vary.

This means that different carriers provide different premiums to their clients, and comparing your options is the best bet to find the lowest price for benefits. By speaking to a licensed insurance agent, you can determine which plans are available in your area, your best coverage options, and the lowest price available.

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How to Get Medicare PSA Coverage

Having Medicare pay for a prostate-specific antigen PSA test can be done with the right benefits and within Medicare’s guidelines. By testing for prostate cancer early on, you can better your chances of treating the disease, as early detection is fundamental.

Our team of licensed insurance agents can help answer your questions and review your coverage to ensure that your annual checkups are covered by your benefits. Avoid overpaying for coverage by comparing Medicare benefits that fit your healthcare and budget needs. Call us today at the number above or fill out an online rate form to get started!

Kayla Hopkins

Kayla Hopkins

Content Editor
Kayla Hopkins is an accomplished writer and Medicare guru serving as the Editor of MedicareFAQ.com. Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Insurance Agent, she brings a wealth of knowledge and expertise to her writing.
Ashlee Zareczny

Ashlee Zareczny

Compliance Manager
Ashlee Zareczny is the Compliance Manager for MedicareFAQ. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.

10 thoughts on "Does Medicare Cover a PSA Test?"

  1. Specifically, how is it communicated that a test is medically necessary? It really is not as simple as your doctor “deeming” something medically necessary. Something is medically necessary when it is ordered by a doctor evaluating, managing and treating a medical condition, is it not? For males on testosterone, it is medically necessary to monitor PSA every 6 months. This has been communicated to Medicare by ordering CPT 84153 and including ICD-10 E29.1. Yet the lab claim was denied. What additional information is to be provided?

    1. A simple order by a doctor does not determine medical necessity as a doctor could prescribe a cosmetic service or other service that is not “necessary” but is wanted by the patient or recommended by the dr. Medical necessity is ultimately determined by the ICD-10 codes used by the physician when ordering the test/service. The ICD-10 or “diagnosis” code will be the determining factor in telling Medicare if the test is ordered out of necessity or cosmetics. For example, if a patient is getting Botox for fine lines and wrinkles, the ICD-10 code would reflect a cosmetic reasoning. However, if the Botox was ordered for migraine management, the ICD-10 code would reflect the diagnosis as such and the procedure would become medically necessary.

  2. I am 75 years old and every year I get a PSA test on my annual wellness visit. This year Medicare denied it as not being a covered service so my medigap policy paid nothing. Thankfully the path group took a contractual adjustment which left me with a very small amount to pay. It would be great if Medicare would list non-covered services by gender and age group AND MOST OF ALL INCLUDE CPT OR ICD-10 CODES ON the EOB.

    1. Hello Ronald,

      Unfortunately, if your doctor doesn’t deem the PSA test medically necessary, you are unlikely to be covered. This can be frustrating and hopefully will become clearer in the future.

    1. Steve, typically Medicare covers one PSA every 12 months. However, in certain circumstances, they will cover more than one if it is deemed medically necessary by your doctor.

  3. I am 85 years old and my doctor stopped giving me a PSA exam when I turned 80 years old stating Medicare wouldn’t pay for it. Is this factual?

  4. I had a PSA test in November 2020. My Doctor gave me a prescription order for a PSA test in June 2021 as a follow up. He has treated me for BPH and has me on a medication. Will Medicare pay for this test since I have BPH and the Doctor has ordered the follow up test although it has not been a year? Would this be diagnostic and not preventative as far as the test goes? will Medicare pay the claim?

    1. Hi Ernest! As long as the doctors deem the second test medically necessary, Medicare will cover it. You can confirm this with their billing department. They will know the proper CPT codes to use.

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