Anthem Blue Cross Connecticut CG-LAB-28 Prostate Specific Antigen Testing Form

This document addresses the use of laboratory testing for prostate specific antigen (PSA) levels. Low levels of serum total PSA are normal, higher levels of serum PSA may indicate a malignancy. PSA testing is considered a relatively non-specific tool as elevated PSA levels may also have benign causes.

Note: This document does not address the use of following PSA laboratory tests:

• Complexed PSA
• Free PSA
• Prostate Health Index (PHI)

Note: Please see the following document for information on gene expression and genomic biomarker testing:

• GENE.00009 Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer

Clinical Indications

Medically Necessary:

Prostate specific antigen (PSA) testing is considered medically necessary for any of the following indications:

• Screening for prostate cancer, or
• Evaluation of  signs or symptoms suggestive of prostate cancer; or
• Individuals with previous elevated or rising PSA levels; or
• Individuals with current or past history of prostate cancer.

Not Medically Necessary:

PSA testing is considered not medically necessary for all other indications not listed above.