Prostate Specific Antigen (PSA)
DESCRIPTION
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.
POLICY
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.)
MEDICAL APPROPRIATENESS
Total prostate specific antigen (PSA) is considered medically appropriate if ANY ONE of the following criteria is met:
Individuals age 40 to 49 years old who are at high risk of developing prostate cancer and/or have a family history of prostate cancer as evidenced by ANY ONE of the following:
The individual is African-American
The individual has a diagnosis, or a first-degree relative with a diagnosis, of ANY ONE of the following:
A cancer known to be associated with an increased risk of prostate cancer
A genetic alteration known to be associated with an increased risk of prostate cancer
A first-degree relative with a diagnosis of prostate cancer
A first-degree relative died as a result of prostate cancer
Individuals age 50 years or older
Other individuals if a physician determines that early detection for prostate cancer is 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:
Health Benefit Plan
A) Means a hospital or medical expense policy; health, hospital, or medical service corporation contract; policy or agreement entered into by a health insurer; or health maintenance organization contract offered by an employer.
B) Includes a state insurance plan set out in title 8, chapter 27; a policy or contract for health insurance coverage provided under the TennCare medical assistance program or a successor program provided for in title 71, chapter 5; and a policy or contract of health insurance coverage provided under the CoverKids program, or a successor program provided for in title 71, chapter 3.
“Men with a family history of prostate cancer” means men who have a first-degree relative:
A) Who was diagnosed with prostate cancer;
B) Who developed prostate cancer;
C) Whose death was a result of prostate cancer;
D) Who has been diagnosed with a cancer known to be associated with an increased risk of prostate cancer; or
E) Who has a genetic alteration known to be associated with an increased risk of prostate cancer
A health benefit plan shall provide, upon the recommendation of a physician, coverage for the early detection of prostate cancer for:
1) Men forty (40) to forty-nine (49) years of age who are at a high risk of developing prostate cancer, including African-American men, and men with a family history of prostate cancer;
2) Men fifty (50) years of age and older; and
3) Other men if a physician determines that early detection for prostate cancer is medically necessary
IMPORTANT REMINDERS
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 or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
SOURCES
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. Received from BCBST’s Legal Division on May 23, 2024.
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: 7/1/2024
ID_BT
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.