Does G0416 require prior authorization?

No, G0416 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for G0416?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 3.51.

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`G0416`, Surgical pathology, gross and microscopic examinations, for prostate needle

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

3.51

Facility

N/A

Non-Facility

N/A

Documentation Required

Evidence in the medical record to support the specific covered indication being claimed (e.g., pathology showing atypia or high-grade PIN on prior biopsy for stereotactic saturation biopsy).
Documentation of prior biopsy history when considering repeat/saturation biopsy: number and type of prior biopsies (e.g., multiple negative extended TRUS biopsies), and pathology findings such as atypia or high-grade PIN (the policy repeatedly references candidate selection: "high-risk men with multiple negative extended prostate biopsies" and "men with histologic evidence of atypia on prior prostate biopsy, or men with histologic findings of high-grade prostatic intraepithelial neoplasia (PIN) on prior biopsy").

Documentation of PSA values and trends, including persistently rising PSA and PSA density when relevant (policy cites "elevated PSA that is persistently rising" and references studies using PSA thresholds and PSA density criteria).

For MRI-guided biopsy: documentation of pre-biopsy mpMRI images and reporting (PI-RADS score), with MP-MRI suspicious lesions (PI-RADS ≥3) noted as the indication to perform MRI-targeted biopsy (many studies cited use PI-RADS to triage and target lesions).

For know error® DSPA: documentation of a reference DNA sample (cheek swab) taken prior to biopsy, bar-coded specimen container usage, and the forensics lab electronic DSPA report (policy describes the 3-step process and states the lab issues an electronic report).

Procedure documentation: number of cores taken, biopsy approach (transperineal vs transrectal), anesthesia used (saturation biopsy often performed under regional or general anesthesia per some studies), and location/ template mapping of cores (e.g., 24, 36, 50-core templates described in studies).

Key Coverage Criteria

Aetna considers a transperineal stereotactic template-guided saturation prostate biopsy medically necessary for the following indications: Men with 2 prior negative prostate biopsies and a prostate specific antigen (PSA) that is persistently rising; or Men with histologic findings of atypia or high-grade prostatic intraepithelial neoplasia (PIN) on prior biopsy.
Aetna considers prostate saturation biopsy experimental and investigational for all other indications (e.g., surveillance or watchful waiting of persons with a positive prostate biopsy) because there is insufficient evidence on the clinical utility of this procedure for indications other than the ones listed above in the peer-reviewed medical literature.
ICD-10 codes listed as covered diagnoses when selection criteria are met: C61 (Malignant neoplasm of prostate); D07.5 (Carcinoma in situ of prostate [PIN III]); N42.30 - N42.39 (Dysplasia of prostate [PIN I or II]).
CPT/HCPCS/ICD-10 codes listed as 'covered if selection criteria are met' (examples included in policy): CPT 55706 (stereotactic template guided saturation sampling), CPT 55700 (biopsy, prostate; needle or punch...), CPTs 72195-72197 (MRI pelvis) and HCPCS G0416 (surgical pathology for prostate needle biopsy) — covered when the above selection criteria/medical necessity are met.
ICD-10 codes listed as covered if selection criteria are met: C61 (Malignant neoplasm of prostate), D07.5 (Carcinoma in situ of prostate [PIN III]), N42.30 - N42.39 (Dysplasia of prostate [PIN I or II]).
Transperineal template-guided stereotactic saturation prostate biopsy is being proposed as a method to detect prostate cancer in high-risk men with multiple negative extended prostate biopsies, including men with an elevated prostate-specific antigen (PSA) that is persistently rising, men with histologic evidence of atypia on prior prostate biopsy, or men with histologic findings of high-grade prostatic intraepithelial neoplasia (PIN) on prior biopsy.

5 Active Policies

AETNA-CPB-0698, Prostate Biopsy

BCBSIL-SUR717.015, Saturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer, Including Comprehensive 3D Mapping with Biopsy

BCBSMT-SUR717.015, Saturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer, Including Comprehensive 3D Mapping with Biopsy

BCBSNM-SUR717.015, Saturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer, Including Comprehensive 3D Mapping with Biopsy

BCBSOK-SUR717.015, Saturation Biopsy for Diagnosis, Staging and Management of Prostate Cancer, Including Comprehensive 3D Mapping with Biopsy

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G0416, Surgical pathology, gross and microscopic examinations, for prostate needle