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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 one biomarker test, ordered by a physician or other qualified health care professional (i.e., 
NP, CNS, PA) is covered ONCE per year. 
 
PRIOR to potential biopsy, for men >/ 45 years old covered testing includes %fPSA, PHI, Select MDx, 4K 
Score or MyProstate score; in men >/ 50 with a PSA > than 4ng/ml covered testing additionally includes EPI 
and isoPSA. Must have both of the following: 
 
    No other relative indication for prostate biopsy including ANY of the following: 
        DRE suspicious for cancer (e.g., nodules, induration, or asymmetry) 
        Positive multiparametric MRI (Prostate Imaging Reporting and Data System [PI-RADS] =3) (if available) 
        Positive prior biopsy (cancer Grade Group =1, intraductal carcinoma (IDC), atypical intraductal 
proliferation (AIP)) 
        Other major risk factor for prostate cancer including: 
            Ethnicity at higher risk for prostate cancer^ 
            First-degree relative with prostate cancer^ 
            High-penetrance prostate cancer risk gene(s) per NCCN (if known)^ 
    No other relative contraindication for prostate biopsy including ANY of the following: 
        <10 year life expectancy, or otherwise not a candidate for prostate cancer treatment 
        Invasive treatment for benign prostatic disease or taking medications that influence serum PSA levels 
within 6 mo. 
        Active prostatitis on antibiotics 
 
*PSA elevation should be confirmed after a few weeks under standardized conditions (i.e., no ejaculation, 
manipulations, and urinary tract infections) in the same laboratory before considering a biopsy (1). 
 
^Limitation does not apply to EPI 
 
Those men, who need a REPEAT BIOPSY in the setting of patients thought to be at higher risk despite a prior 
negative biopsy, covered testing includes %fPSA, PHI, 4K Score, PCA 3, EPI, Confirm Dx, MyProstate Score and isoPSA with confirmed * moderately elevated PSA (>3ng/ml and <10ng/ml; or PSA >/4ng/ml and < 
10ng/ml in men > 75 years of age) with BOTH of the following: 
 
    No other relative indication for prostate biopsy including ANY of the following: 
        DRE suspicious for cancer (e.g., nodules, induration, or asymmetry) 
        Positive multiparametric MRI (Prostate Imaging Reporting and Data System [PI-RADS] =3) (if available) 
        Positive prior biopsy (cancer Grade Group =1, intraductal carcinoma (IDC), atypical intraductal 
proliferation (AIP)) 
        Other major risk factor for prostate cancer including: 
            Ethnicity at higher risk for prostate cancer 
            First-degree relative with prostate cancer 
            High-penetrance prostate cancer risk gene(s) per NCCN (if known) 
    No other relative contraindication for prostate biopsy including ANY of the following: 
        <10 year life expectancy, or otherwise not a candidate for prostate cancer treatment 
        Invasive treatment for benign prostatic disease or taking medications that influence serum PSA levels 
within 6 mo. 
        Active prostatitis on antibiotics 
 
*PSA elevation should be confirmed after a few weeks under standardized conditions (i.e., no ejaculation, 
manipulations, and urinary tract infections) in the same laboratory before considering a biopsy (1). 
 
You can find these rules in the Local Coverage Determination (LCD) Biomarker Testing for Prostate Cancer 
Diagnosis L37733. 
 
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.