0359U — Onc prst8 ca alys all psa
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Include results of prior PSA testing or, if results are not available, document the symptoms that prompted performance of the IsoPSA test.
- The patient's medical record must include the ordering provider's assessment related to the patient's complaint for that visit and relevant medical history.
- Medical record must contain signed and dated office visit record or operative report; all services ordered or rendered to Medicare beneficiaries must be signed.
- Document risk factors for prostate biopsy in the medical record.
Key Coverage Criteria
- Bill IsoPSA using CPT 0359U for prostate cancer detection or evaluation of prostate-related indications when performed per local coverage policy and supported by an appropriate ICD-10-CM diagnosis that best describes the patient's condition.
- Men age >=50 with a confirmed moderately elevated PSA (>4 and <=25 ng/mL).
- No other relative contraindication to prostate biopsy, specifically life expectancy >=10 years.
- Beneficiary is being actively managed for bladder cancer.
- Use of EndoPredict or MammaPrint for breast cancer with 1–3 positive lymph nodes.
- Member has a diagnosis of ovarian cancer and is being considered for PARP inhibitor therapy.
3 Active Policies
AMBETTER-CG-Onc-Algo-2025.1 — Concert Genetic Oncology: Algorithmic Testing
A59066 — Billing and Coding: Prostate Cancer Detection with IsoPSA
L39284 — Prostate Cancer Detection with IsoPSA
Related Codes
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