J1 MAC: Prostate Molecular Markers Not Covered

Billing and coding guidelines for prostate molecular marker claims submitted to Palmetto GBA have changed. The Part B Medicare administrative contractor (MAC) for jurisdiction 1 (American Samoa, California, Guam, Hawaii, Nevada, and Northern Mariana Islands) has determined the service to be medically unnecessary and will not reimburse physicians for HOXD3, PTEN, and ERG molecular markers.

Among other considerations, patients should be informed that molecular markers are not covered under Medicare, and an Advanced Beneficiary Notice (ABN) for the service should be retained on file.

Complete instructions for how to submit a claim to receive a service denial were posted June 1 on Palmetto’s website.


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