Appeal type: unknown
Decision: unknown

Please note, the Local Coverage Determination (LCD), L37013 is not binding in this case. The LCD does not have Part B jurisdiction where the services were provided.
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that the 4Kscore test will be considered medically reasonable and necessary when all the following are met:
1. When all of the components of the algorithm are present.
2. Testing of men 45 years of age and older, prior to an initial biopsy or following a negative biopsy, who have a confirmed* moderately elevated PSA (greater than 3 and less than 10 ng/mL; greater than or equal to 4 and less than 10 ng/mL in men greater than 75 years of age) when BOTH of the following are present:
&#8722; No other relative indication** for prostate biopsy including ANY of the following: (this may not be an all-inclusive list)
&#8722; DRE suspicious for cancer should be encouraged to undergo biopsy
&#8722; Persistent and significant increase in PSA should be encouraged to undergo biopsy
&#8722; Positive multiparametric magnetic resonance imaging (MRI) (if done)
&#8722; Other major risk factor for prostate cancer including: (this may not be an all-inclusive list)
&#9642; Ethnicity at higher risk for prostate cancer
&#9642; First-degree relative with prostate cancer
&#9642; High-penetrance prostate cancer risk gene(s) per the National Comprehensive Cancer Network (NCCN) (if known)
&#8722; No other relative contraindication** for prostate biopsy including ANY of the following:
&#8722; Less than a 10-year life expectancy
&#8722; Benign disease not ruled out.
*PSA elevation should be verified after a few weeks under standardized conditions (e.g. no ejaculation, manipulations, and urinary tract infections, no medications such as 5&#945;-reductase) in the same laboratory or other Clinical Laboratory Improvement Amendments (CLIA) approved laboratory before considering a biopsy.
**The relative indications and contraindications are not absolute. When it is determined that the 4Kscore test is medically reasonable and necessary in a beneficiary with one of the relative indications or contraindications for prostate biopsy the medical record must support the medical necessity for the test and there must be documented evidence of shared decision making between the patient and provider. This supporting documentation must be provided to the laboratory at the time of ordering the test.
3. Presence of shared decision making between the ordering provider and the beneficiary concerning the 4Kscore testing.
You can find this rule in the Local Coverage Determination for 4Kscore Test Algorithm, L37792 (eff 12/30/19).
The rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.