Pca3....help!!!

Codergirl93

Networker
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Sturtevant, WI
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Hello everyone,

So my providers do PCA3 on there patients. Recently we have been getting denials for them saying not medically necessary. I did look up the Medicare guidelines and it stated that if the patient has had biopsy done first and are negative for prostate cancer. From what my providers nurse tells me is that the provider wants to the PCA3 instead of doing a biopsy.

Does anyone else have this issue or know how to handle this?

Thanks!
 

JEYCPC

Expert
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Frederick, MD
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I did look up the Medicare guidelines and it stated that if the patient has had biopsy done first and are negative for prostate cancer. From what my providers nurse tells me is that the provider wants to the PCA3 instead of doing a biopsy.

Not sure what you mean. That said PCA3 is a gene-based test to help deciding if biopsy is really needed. So if it's done after a biopsy, Medicare would likely not pay for it.

I found this as well:
The PCA3 Assay is a simple test: following a digital rectal examination (DRE), cancerous cells with high levels of PCA3 are shed from the prostate into the urine. A urine sample is then collected (click on animation to visualise). This urine sample is sent to a laboratory to determine the PCA3 Score. A high PCA3 Score indicates an increased likelihood of a positive biopsy, i.e. presence of cancer cells in the prostate. A low PCA3 Score indicates a decreased likelihood of a positive biopsy. If the PCA3 Score is low, a biopsy may be delayed or eventually avoided. In this way, the PCA3 Assay may help to avoid many unnecessary first biopsies and the potential discomfort and complications (pain, bleeding and infections) for the men involved.

My lesson for the day. :)
 
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