Medicare will pay for PSMA scans if ...
Updated: Jun 1, 2022
This is my attempt to clarify the rules for PSMA PET/CT medicare coverage.
I am not a doctor.
A man may be entitled to Medicare coverage up to three times in a lifetime:
Once
before any direct treatment to the prostate (surgery or radiation) for intermediate risk
or high risk.
Twice
after initial direct treatment (surgery or radiation) to the prostate if further treatment to the prostate is being considered for recurrent cancer.
Intermediate risk
At least one of:
PSA 10-20;
Grade group 2 or 3 (same as Gleason score 7);
Stage T2b;
and none of the high risk features.
High risk
At least one of:
PSA more than 20;
Grade group 4 or 5 (same as Gleason score 8, 9, 10);
Stage T2c or T3 or T4
Recurrent cancer
After radiation as the first direct treatment to the prostate:
PSA rises by 2 more than the lowest PSA after radiation.
After surgery as the first direct treatment to the prostate:
PSA does not fall to undetectable levels OR
PSA starts to rise after surgery.
I am not a doctor.
You can search for the current rules in Google by:
Medicare item 61563 61564 fact sheet