NCD190.31

 

PROSTATE SPECIFIC ANTIGEN

 

Effective Date of this Version

1/1/2003

 

Benefit Category

• Diagnostic Laboratory Tests.

• Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

 

Item/Service Description

• Prostate Specific Antigen (PSA), a tumor marker for adenocarcinoma of the prostate, can predict residual tumor in the post-operative phase of prostate cancer.

o Three to six months after radical prostatectomy, PSA is reported to provide a sensitive indicator of persistent disease.

o Six months following introduction of antiandrogen therapy, PSA is reported as capable of distinguishing patients with favorable response from those in whom limited response is anticipated.

• PSA when used in conjunction with other prostate cancer tests, such as digital rectal examination, may assist in the decision-making process for diagnosing prostate cancer.

o PSA also, serves as a marker in following the progress of most prostate tumors once a diagnosis has been established.

o This test is also an aid in the management of prostate cancer patients and in detecting metastatic or persistent disease in patients following treatment.

 

Indications and Limitations of Coverage

 

Indications

• PSA is of proven value in differentiating benign from malignant disease in men with lower urinary tract signs and symptoms:

o Hematuria.

o Slow urine stream.

o Hesitancy.

o Urgency.

o Frequency.

o Nocturia.

o Incontinence.

o Patients with palpably abnormal prostate glands on physician exam.

o In patients with other laboratory or imaging studies that suggest the possibility of a malignant prostate disorder.

• PSA is also a marker used to follow the progress of prostate cancer once a diagnosis has been established, such as in detecting metastatic or persistent disease in patients who may require additional treatment.

• PSA testing may also be useful in the differential diagnosis of men presenting with as yet undiagnosed disseminated metastatic disease.

 

Limitations

• Generally, for patients with lower urinary tract signs or symptoms, the test is performed only ONCE PER YEAR unless there is a change in the patient's medical condition.

• Testing with a diagnosis of in situ carcinoma is NOT reasonably done more frequently than once, unless the result is abnormal, in which case the test may be repeated ONCE.

• Note: Scroll down for links to the quarterly Covered Code Lists (including narrative).

 

Cross Reference

• Also see the Medicare Claims Processing Manual, Chapter 120, Clinical Laboratory Services Based on Negotiated Rulemaking.

 

Coverage Transmittal Link

• http://www.cms.gov/transmittals/downloads/R17NCD.pdf

 

Other

Covered Code Lists (including narrative)

• January 2013

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Changes to Lab NCD Edit Software

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Coding Analyses for Labs (CALs)

• This NCD has been or is currently being reviewed under the National Coverage Determination process.

• The following are existing associations with CALs, from the Coding Analyses for Labs database.

• Original consideration for Codes That Are Not Covered by Medicare (Removal of ICD-9-CM Code V76.44, Prostate Cancer Screening, From the List) (CAG-00297N)

• Original consideration for Prostate Specific Antigen (Addition of ICD-9-CM 600.00, Hypertrophy (benign) of Prostate Without Urinary Obstruction, as a covered indication) (CAG-00326N)

• Original consideration for Prostate Specific Antigen (Inclusion of ICD-9-CM Code 600.01 for BPH with Urine Obstruction) (CAG-00232N)

• Original consideration for PSA (Addition of ICD-9-CM 600.10, Nodular prostate without urinary obstruction and 600.11, with urinary obstruction, as covered indications) (CAG-00331N)

• Original consideration for PSA (Addition of ICD-9-CM 600.21, Benign localized hyperplasia of prostate with urinary obstruction as a covered indication) (CAG-00332N)

 

Medicare NCD Link