CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB006

Prostate Specific Antigen (PSA) Testing

Governance of reimbursement and clinical criteria for total PSA and percent free PSA testing for prostate cancer screening, diagnosis, and monitoring for Blue Cross Blue Shield New Mexico members and providers.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyProstate Specific Antigen (PSA) Testing

Policy CodePolicy CPCPLAB006

Change TypeCriteria clarifications and reimbursement guidance updates

Effective DateSep 5, 2025

Next Review Date

Key ActionUse the listed reimbursement criteria and procedure codes to determine coverage and submit accurate documentation; percent free PSA is not reimbursable as a first-line screening test.

SourceLink

POLICY UPDATE CHANGES

Age wording in reimbursement criteria 1 and 2 changed to 'and older (see Note 1)' and item #3 was removed from the prior wording.

Screening interval for certain patients >75 years was updated from '1-4 year' to '1-3 year' and wording around comorbidity was replaced with '(see Note 1)'.

Percent free PSA is not reimbursable as a first-line screening test and free-to-total or complexed PSA tests are not reimbursable for routine screening.

45minimum age for average-risk screening consideration

40minimum age for annual screening with risk factors

75special consideration age

4procedure codes listed

Coverage Criteria for PSA Testing

Covered Uses and Criteria

Covered when the following age-, risk-, and clinical-condition criteria are met:

Screening — average and elevated risk: 1) For average-risk individuals 45 years of age and older: screening with total PSA may be reimbursable. 2) For individuals 40 years of age and older: annual screening with total PSA may be reimbursable when ANY of the following are present: (a) African ancestry; (b) germline mutations that increase prostate cancer risk; (c) suspicious family history.age and risk criteria

See Note 1 for guidance on testing after 75 years.

Repeat screening intervals based on prior PSA and age: For individuals with previous total PSA results: a) Individuals <76 years with total PSA <1 ng/mL and normal DRE (if done): repeat screening at 2–4 year intervals; b) Individuals <76 years with total PSA 1–3 ng/mL and normal DRE (if done): repeat screening at 1–2 year intervals; c) Individuals >75 years with total PSA <4 ng/mL and normal DRE (if done) and no other indications for biopsy: repeat screening in select patients at 1–3 year intervals.PSA ranges and ages

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyProstate Specific Antigen (PSA) Testing

Policy CodePolicy CPCPLAB006

Change TypeCriteria clarifications and reimbursement guidance updates

Effective DateSep 5, 2025

Next Review Date

Key ActionUse the listed reimbursement criteria and procedure codes to determine coverage and submit accurate documentation; percent free PSA is not reimbursable as a first-line screening test.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions, Billing, and Documentation

Prior Authorization

Prior Authorization and Listed Codes

Prior authorization is not explicitly required by this policy; however, reimbursement is subject to the plan's lab management criteria and the member's specific plan documents. Providers should verify benefit coverage and any prior authorization requirements with the member's plan or benefit document before providing services.

Not all requirements apply to every product — review the member's plan documents for eligibility and prior authorization rules.
Listed procedure codes may not be all-encompassing and inclusion does not guarantee coverage or reimbursement: 84152, 84153, 84154, G0103.

Documentation Required

Providers are responsible for submitting accurate and complete documentation for services performed. Claims should be coded using valid HIPAA-approved code sets and in accordance with industry-standard coding guidelines (for example: Uniform Billing, AMA CPT, HCPCS, ICD-10-CM/PCS, NDCs, DRG guidance, CMS NCCI and related policy manuals).

Submit claims using valid code combinations from HIPAA-approved code sets.
Follow industry-standard coding guidelines including CPT, HCPCS, ICD-10, National Drug Codes, CMS NCCI edits, and other applicable manuals.

Denial Risk

Coding and Claim Submission — Denial Risk

Claims are subject to code edit protocols and review. A claim may be denied or reimbursement adjusted if coding does not follow industry-standard code sets, if services are ineligible under the member's plan, or if additional documentation is not provided upon request.

Claims may be reviewed against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic.
Upon request, providers must submit additional documentation to support medical necessity and eligibility.

Background and Clinical Context

Prostate-specific antigen (PSA) testing has roles across screening, diagnosis, and monitoring of prostate cancer. Total PSA is the primary test considered for age- and risk-based screening under this policy, while percent free PSA and related ratios may be useful in select diagnostic contexts but are excluded from routine first-line screening. Recommendations for testing vary by age and individual risk factors; in older adults the policy references guideline caution against widespread testing. Per the referenced guideline, testing after age 75 should be limited to very healthy men with little or no comorbidity, since routine testing in this population increases the risk of overdiagnosis. The policy defines “individuals” as persons who have a prostate or were born with a prostate.

OpenPayer

Prostate Specific Antigen (PSA) Testing

Coverage Criteria for PSA Testing

Procedure Codes

Provider Actions, Billing, and Documentation

Background and Clinical Context

Definitions

84152	PSA, total
84153	PSA, free
84154	PSA, complexed
G0103	Prostate cancer screening; measurement of PSA