Medicare will pay for PSMA scans if ...

Updated: Jun 1

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

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