Appeal type: unknown
Decision: unknown

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) 422.101.
The rules say that Section 4103 of the Balanced Budget Act of 1997 provides for coverage of certain prostate
cancer screening tests subject to certain coverage, frequency, and payment limitations. Medicare will cover
prostate cancer screening tests/procedures for the early detection of prostate cancer. Coverage of prostate
cancer screening tests includes the following procedures furnished to an individual for the early detection of
prostate cancer: Screening digital rectal examination; and Screening prostate specific antigen blood test
Screening digital rectal examinations are covered at a frequency of once every 12 months for men who have
attained age 50 (at least 11 months have passed following the month in which the last Medicare-covered
screening digital rectal examination was performed). Screening digital rectal examination means a clinical
examination of an individual's prostate for nodules or other abnormalities of the prostate. This screening must
be performed by a doctor of medicine or osteopathy (as defined in 1861(r)(1) of the Act), or by a physician
assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife (as defined in 1861(aa) and
1861(gg) of the Act) who is authorized under State law to perform the examination, fully knowledgeable
about the beneficiary's medical condition, and would be responsible for using the results of any examination
performed in the overall management of the beneficiary's specific medical problem.
Screening prostate specific antigen tests are covered at a frequency of once every 12 months for men who have
attained age 50 (at least 11 months have passed following the month in which the last Medicare-covered
screening prostate specific antigen test was performed). Screening prostate specific antigen tests (PSA) means a
test to detect the marker for adenocarcinoma of prostate. PSA is a reliable immunocytochemical marker for
primary and metastatic adenocarcinoma of prostate. This screening must be ordered by the beneficiary's
physician or by the beneficiary's physician assistant, nurse practitioner, clinical nurse specialist, or certified
nurse midwife (the term "attending physician" is defined in 1861(r)(1) of the Act to mean a doctor of
medicine or osteopathy and the terms "physician assistant, nurse practitioner, clinical nurse specialist, or
certified nurse midwife" are defined in 1861(aa) and 1861(gg) of the Act) who is fully knowledgeable about
the beneficiary's medical condition, and who would be responsible for using the results of any examination
(test) performed in the overall management of the beneficiary's specific medical problem.
You can find this information in the National Coverage Determination (NCD) for Prostate Cancer Screening
Tests (210.1).
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. The health
plan contract says that there is no coinsurance, copayment, or deductible for an annual PSA test or Digital
rectal exam. For men age 50 and older, covered services include the following - once every 12 months:
Digital rectal exam
Prostate Specific Antigen (PSA) test
When services other than preventive are performed, the cost-share (copayment/coinsurance) associated with the
other service will apply. You can find this information in Chapter 4 on pages 73-74 of the plan's 2019 Evidence
of Coverage.