About this policy
Jurisdiction: J15 MAC Part B. States: Kentucky, Ohio. Type: Active LCD
Coverage indications
The IsoPSA® test will be considered medically reasonable and necessary when all the following are met: Testing of men 50 years of age and older who have a confirmed* moderately elevated PSA (greater than 4 and ≤ 25 ng/mL) AND No other relative contraindication for prostate biopsy including: Less than a 10-year life expectancy *PSA elevation should be verified after a few weeks under standardized conditions (e.g., no ejaculation, manipulations, and urinary tract infections) in the same laboratory or other CLIA approved laboratory before considering a biopsy.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.