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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 prostate cancer is the most diagnosed, non-cutaneous malignancy, and the third leading cause 
of cancer-related deaths in American men (behind lung and colorectal cancer). Approximately 165,000 men are 
expected to be diagnosed with prostate cancer in 2018, with approximately 18% dying of the disease (2). 
However, prostate cancer is a heterogeneous disease with a clinical course ranging from indolent to life-
threatening.  
 
The provision of limited coverage for Biomarker Testing for Prostate Cancer Diagnosis has the potential to not 
only decrease biopsies (and associated risks), but also of reducing detection of indolent disease (and the 
attendant risks of overtreatment). The primary aim is to increase specificity compared with PSA without 
decreasing the sensitivity to diagnose high-risk prostate cancer. 
 
One biomarker test, ordered by a physician or other qualified health care professional (i.e., NP, CNS, PA) is 
covered ONCE per year. For men >/ 45 years old receiving testing prior to potential biopsy, covered testing 
includes %fPSA, PHI, Select MDx, 4K Score or MyProstate score, in men >/ 50 covered testing additionally 
includes EPI and isoPSA in those men >/ 50 with a PSA > than 4ng/ml. 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, 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. 
 
You can find this rule 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.