Laboratory - Prostate Biopsies
Defines Humana Medicare Advantage payment policy for reimbursement of surgical pathology (gross and microscopic) for prostate needle biopsy (CPT G0416) and identifies the clinical indications required for reimbursement; applies to providers submitting claims for Humana Medicare Advantage members.
No material clinical or coverage changes in this revision.
Reimbursement criteria
Reimbursement criteria for G0416
CPT code G0416 is reimbursable for Medicare Advantage members only when the biopsy is performed on patients with one of the following clinical indications:
ONE of the following must be present
- Benign neoplasm of prostate
- Dysplasia of prostate
- Elevated prostate specific antigen (PSA)
- Enlarged or nodular prostate
- Prostate cancer
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.