CurrentBlue Cross Blue Shield - TexasPolicy CPCPLABOO6

Prostate Specific Antigen (PSA) Testing

Reimbursement and coding criteria for prostate cancer screening, follow-up, diagnostic, and monitoring use of total PSA and percent free PSA tests under Blue Cross and Blue Shield of Texas plans; applies to providers submitting claims for members covered by BCBSTX.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyProstate Specific Antigen (PSA) Testing

Policy CodePolicy CPCPLABOO6

Change TypeRevised age thresholds and screening interval guidance

Effective DateSep 5, 2025

Next Review DateN/A

Key ActionSubmit accurate coding and supporting documentation; claims are subject to review and plan documents govern in conflicts.

SourceLink

POLICY UPDATE CHANGES

Reimbursement criteria language updated to use '45 years of age and older' for average-risk screening and '40 years of age and older' for annual screening in higher-risk groups; age-range phrasing 'and older (see Note 1)' replaced prior '-75' wording.

Screening interval for individuals >75 (now described as 'select individuals greater than 75 years of age') when total PSA is <4 ng/ml updated to repeat screening at '1-3 year intervals' (was previously 1-4 years).

Removed reference to TRUS-guided biopsy from follow-up/reimbursement examples.

45+avg-risk screening age

40+higher-risk annual age

1-2 yrsrepeat interval PSA 1-3 ng/ml (<76)

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PSA Testing Coverage Criteria

PSA Coverage Criteria

Reimbursement allowed when ALL of the following age-, risk-, interval-, and indication-based conditions are met for total PSA testing; percent free PSA has limited reimbursable uses and is not reimbursable for routine first‑line screening.

ALL of the following

Screening eligibility
- Average‑risk screening: individuals 45 years and older (see Note 1) — total PSA test may be reimbursable.
- Higher‑risk annual screening: individuals 40 years and older (see Note 1) — total PSA annually may be reimbursable when one or more of the following are present: germline mutations that increase risk, African ancestry, or a suspicious family history.
Repeat screening intervals for individuals with prior total PSA results
- Individuals less than 76 years of age with total PSA <1 ng/ml and DRE normal (if done): repeat screening at 2–4 year intervals.
- Individuals less than 76 years of age with total PSA 1–3 ng/ml and DRE normal (if done): repeat screening at 1–2 year intervals.
- Select individuals greater than 75 years of age (see Note 1) with total PSA <4 ng/ml and DRE normal (if done) and no other indications for biopsy: repeat screening at 1–3 year intervals.
Follow‑up and additional testing potentially reimbursable
- Percent free PSA, or follow‑up in 6–12 months with total PSA, may be reimbursable when indicated (see specific clinical circumstances).
- Percent free PSA may be reimbursable for select individuals greater than 75 years of age with total PSA >4 ng/ml or a very suspicious DRE.
- Percent free PSA may be reimbursable for individuals less than 76 years of age with total PSA >3 ng/ml and/or a very suspicious DRE.
- Percent free PSA may be reimbursable for individuals thought to be at higher risk despite at least one prior negative prostate biopsy (follow‑up testing).
Diagnostic and monitoring uses (reimbursable)
- Initial prostate cancer diagnosis in individuals with signs or symptoms of prostate cancer (see Note 2).
- Ongoing monitoring of individuals who have undergone tumor resection or prostatectomy.
- Detecting disease recurrence.
- Monitoring response to therapy.
Not reimbursable
- Percent free PSA, free‑to‑total PSA ratio, and/or complexed PSA tests for routine screening of prostate cancer are not reimbursable.
- Percent free PSA as a first‑line screening test for prostate cancer is not reimbursable.

ALL of the following

Screening age thresholds reference Note 1: testing after 75 years should be limited to very healthy individuals with little or no comorbidity; term 'individuals' refers to people who have a prostate or were born with a prostate.

ALL of the following

Documentation: providers must support reimbursement claims with appropriate clinical information (e.g., PSA values, DRE findings, risk factors, symptom documentation) consistent with policy notes and clinical guidance.

Procedure and Threshold Coding

Procedure Codes (non-exhaustive)mixed

No codes listed

PSA level thresholds referenced

Total PSA <1 ng/mlReferenced as a threshold for repeat screening (repeat at 2–4 year intervals for individuals <76 years when DRE normal)

Total PSA 1–3 ng/mlReferenced as a threshold for repeat screening (repeat at 1–2 year intervals for individuals <76 years when DRE normal)

Total PSA >3 ng/mlReferenced as an indication for follow-up or further evaluation (reimbursable in select individuals <76 years or with very suspicious DRE)

Total PSA >4 ng/mlReferenced as a threshold for follow-up in select individuals >75 years (may prompt percent free PSA or follow-up in 6–12 months)

Documentation, Claims, and Provider Responsibilities

Documentation Required

Documentation and Claims Review

Providers are responsible for submitting accurate, complete documentation and correctly coded claims using HIPAA-approved code sets. Claims must follow industry-standard coding guidelines and referenced authorities, including but not limited to: Uniform Billing Editor; American Medical Association Current Procedural Terminology (CPT); Healthcare Common Procedure Coding System (HCPCS); ICD-10-CM and ICD-10-PCS; National Drug Codes (NDC); Diagnosis Related Group (DRG) guidelines; and Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) policy manual, CCI table edits, and related coding resources. Billing should reflect appropriate code combinations and applicable modifiers per payer and coding guidance.

Submit documentation supporting medical necessity upon request (e.g., clinical notes, lab requisitions, results).
Claims are subject to code-edit protocols and automated coding software logic; edits may result in payment adjustments or denial.
Providers must follow any product-specific lab management and reimbursement criteria; not all requirements apply to every product—verify member plan documents for coverage and eligibility.
When plan documents, provider contracts, and this Clinical Payment and Coding Policy conflict, the governing document controls: plan documents govern member entitlement discrepancies; provider contracts govern contractual discrepancies.
BCBSTX may exercise reasonable discretion in applying this policy and has final discretionary authority to interpret and apply policy to the extent allowed by applicable plan documents.

Definitions

Individuals

DefinitionRefers to individuals who have a prostate or were born with a prostate (see Note 1)

Context of useUsed throughout the policy to define the population eligible for PSA screening, follow-up, diagnostic, and monitoring criteria

Age considerationsNote 1 clarifies testing after age 75 should be limited to very healthy individuals with little or no comorbidity

Percent free PSA

DefinitionPercent free PSA is a follow-up test (free-to-total PSA ratio) reimbursable in select clinical circumstances, not for routine first-line screening

When reimbursableMay be reimbursable as follow-up when total PSA results or clinical findings indicate further evaluation (e.g., total PSA >3 ng/ml in <76 yrs, total PSA >4 ng/ml in select >75 yrs)