CurrentHumanaPolicy LAB2O23004

Laboratory Prostate Specific Antigen (PSA) Testing

Payment and reimbursement guidance for PSA laboratory testing for Humana Medicare Advantage products, including when percent free PSA (CPT 84154) is reimbursable and references to applicable Medicare LCD/NCDs and clinical guidance.

Policy Summary

PayerHumana

PolicyLaboratory Prostate Specific Antigen (PSA) Testing

Policy CodePolicy LAB2O23004

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit percent free PSA (84154) only for high‑risk individuals with signs or symptoms of prostate cancer per policy criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

84154procedure code called out for percent free PSA reimbursement

Medicare Advantageapplies to product type

03/2023, 11/2024document dates reported

NGS states exceptedgeographic reimbursement exception for 84154

Reimbursement Criteria

Reimbursement criteria for percent free PSA (CPT 84154)

Covered when ALL of the following are met:

Procedure code 84154 (percent free PSA) is reimbursable only for high-risk individuals exhibiting signs or symptoms of prostate cancer.

Signs or symptoms (one or more):

Problems urinating, including a slow or weak urinary stream or the need to urinate more often, especially at night.
Blood in the urine or semen.
Trouble getting an erection (erectile dysfunction or ED).

Policy Summary

PayerHumana

PolicyLaboratory Prostate Specific Antigen (PSA) Testing

Policy CodePolicy LAB2O23004

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit percent free PSA (84154) only for high‑risk individuals with signs or symptoms of prostate cancer per policy criteria.

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.

Applicable Procedure Codes & Clinical Indications

PSA testing codes referencedCPTCovered

84154

Percent free PSA

inv-03: Clinical indication requirement for 84154

Applicable CPT code84154 (Percent free PSA)

Reimbursement conditionReimbursable only for high-risk individuals who exhibit any signs or symptoms of prostate cancer.

Applicable productHumana Medicare Advantage plans (claims remain subject to medical necessity, reasonableness, and other plan requirements)

Geographic exceptionApplies to all Medicare jurisdictions except states administered by National Government Services, Inc., per policy note.

Billing and Provider Requirements

Prior Authorization

Prior Authorization / Reimbursement Condition for CPT 84154

Percent free PSA (CPT 84154) is only reimbursable for Medicare Advantage members when prior authorization conditions are met and when the member has signs or symptoms suggestive of prostate cancer. Providers must obtain prior authorization before billing CPT 84154 for Medicare Advantage members except where an applicable Original Medicare NCD or LCD specifies otherwise. Claims submitted without required prior authorization may be denied or result in reimbursement denial.

Affected code: CPT 84154
Reimbursable only when member has signs or symptoms of prostate cancer (examples include: problems urinating such as slow or weak stream or nocturia; blood in urine or semen; erectile dysfunction; male genital pain or dysfunction; bone pain from metastatic disease; weakness or numbness in the legs or loss of bladder/bowel control from spinal cord compression)
Applies to all Medicare jurisdictions except states awarded to National Government Services, Inc.
Prior authorization requirement applies to Medicare Advantage plans unless an Original Medicare NCD or LCD establishes alternate criteria

Definitions — High-Risk Signs & Symptoms

inv-05: High-risk individuals with signs and symptoms of prostate cancer

Defined signs/symptoms - urinaryProblems urinating, including a slow or weak urinary stream or the need to urinate more often, especially at night.

Defined signs/symptoms - bloodBlood in the urine or semen.

Defined signs/symptoms - sexual dysfunctionTrouble getting an erection (erectile dysfunction or ED); male genital organ dysfunction or pain.

Defined signs/symptoms - metastatic painPain in the hips, back (spine), chest (ribs), or other areas from cancer that has spread to bones.

Defined signs/symptoms - neurologicWeakness or numbness in the legs or feet, or loss of bladder or bowel control from cancer pressing on the spinal cord.