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.