CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABOOG

Prostate Specific Antigen (PSA) Testing

This policy governs reimbursement criteria for PSA and related laboratory testing for prostate cancer screening, diagnosis, and monitoring for Blue Cross Blue Shield of New Mexico members and affects providers submitting claims for these services.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyProstate Specific Antigen (PSA) Testing

Policy CodePolicy CPCPLABOOG

Change TypeRevised (operational edits and reference updates)

Effective DateJan 15, 2025

Next Review Date

Key ActionProviders must submit accurate documentation and use valid HIPAA-approved code sets; claims may require additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity; TRUS-guided biopsy and DRE were removed from statement #5 and prostate cancer was added to #7d.

Document updated with literature review and references revised.

45-75Average-risk reimbursable age

40-75Higher-risk annual screening age

over 75Select over-75 screening

1-4 yrsRepeat screening interval

PSA Testing Coverage Criteria

PSA testing coverage criteria

Covered when ALL of the following applicable scenarios are met:

Screening: average risk: For average-risk individuals 45-75 years of age, screening for prostate cancer with the total prostate‑specific antigen (total PSA) test may be reimbursable.

Screening: higher risk (annual)

Individual is of African ancestry
Suspicious family history for prostate cancer
Germline mutation that increases risk for prostate cancer

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyProstate Specific Antigen (PSA) Testing

Policy CodePolicy CPCPLABOOG

Change TypeRevised (operational edits and reference updates)

Effective DateJan 15, 2025

Next Review Date

Key ActionProviders must submit accurate documentation and use valid HIPAA-approved code sets; claims may require additional documentation upon request.

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.

Screening: older adults (>75): For individuals over 75 years of age who have little or no comorbidities (very healthy individuals), screening with total PSA may be reimbursable.

Repeat screening based on prior PSA and age

Individuals <76 years with total PSA <1 ng/mL and normal DRE (if performed): repeat screening at 2–4 year intervals
Individuals <76 years with total PSA 1–3 ng/mL: (clinical guidance provided for repeat screening)
Individuals >75 years with total PSA <4 ng/mL and normal DRE (if performed) and no other indications for biopsy: repeat screening in select very healthy patients at 1–4 year intervals

Triage / follow‑up testing

Individuals <76 years with total PSA >3 ng/mL and/or a very suspicious DRE
Select individuals >75 years (very healthy with little or no comorbidity) with total PSA >4 ng/mL or a very suspicious DRE
Individuals thought to be at higher risk despite at least one prior negative prostate biopsy: follow‑up testing with percent free PSA may be reimbursable

Diagnosis and monitoring

Initial diagnosis in individuals with signs or symptoms of prostate cancer
Ongoing monitoring after tumor resection or prostatectomy
Follow‑up of individuals with a current or prior diagnosis of prostate cancer
Monitoring response to prostate cancer therapy
Detecting disease recurrence

Not reimbursable for routine screening: Percent free PSA, free‑to‑total PSA ratio, and/or complexed PSA tests are NOT reimbursable for routine screening; percent free PSA should not be used as a first‑line screening test for prostate cancer.

Procedure Codes and Thresholds

Procedure codes notemixed

No codes listed

PSA thresholds referenced for follow-up

PSA <1 ng/mLRepeat screening every 2-4 years for individuals <76 years when total PSA is <1 ng/mL and DRE is normal (if done).

PSA 1-3 ng/mLGuidance exists for individuals <76 years with total PSA 1-3 ng/mL for repeat screening frequency (see policy).

PSA >3 ng/mLFor individuals <76 years with total PSA >3 ng/mL and/or a very suspicious DRE, percent free PSA or follow-up total PSA in 6-12 months may be reimbursable.

PSA >4 ng/mLFor select individuals >75 years (very healthy with little or no comorbidity) with total PSA >4 ng/mL or a very suspicious DRE, percent free PSA or 6-12 month total PSA follow-up may be reimbursable.

Documentation and Claims Submission

Documentation Required

Submit accurate documentation and HIPAA‑approved codes; claims subject to review

Providers must submit accurate documentation of services performed and submit claims using valid code combinations from HIPAA‑approved code sets. Claims are subject to code edit protocols and claim review against benefit coverage, provider contract language, medical and coding policies, and coding software logic; additional documentation may be requested.

Use valid code combinations from HIPAA‑approved code sets (e.g., CPT, HCPCS, ICD‑10).
Code claims according to industry standard coding guidelines and applicable CCI/ CMS edits.
Be prepared to provide additional documentation upon request to support medical necessity and coding.

Key Definitions

Individual (definition and related screening context)

Definition of IndividualRefers to persons who have a prostate or were born with a prostate; screening recommendations reference health status and comorbidity (e.g., 'very healthy individuals with little or no comorbidity').

Screening age—average riskAverage-risk individuals 45-75 years: screening with total PSA may be reimbursable.

Screening age—higher riskIndividuals 40-75 years: annual screening with total PSA may be reimbursable when of African ancestry, have suspicious family history, or have germline mutations increasing risk.

Screening over 75For individuals >75 years with little or no comorbidity, screening with total PSA may be reimbursable only in very healthy select patients.