Prostate Biopsy

Aetna covers transperineal stereotactic template‑guided saturation biopsy only for men with two prior negative biopsies and persistently rising PSA or for men with atypia/high‑grade PIN, and covers TRUS‑guided and MRI‑guided (transperineal/transrectal, in‑bore or MRI‑TRUS fusion) prostate biopsies for diagnosis, follow‑up, and active surveillance when criteria are met; it deems saturation biopsy and several emerging techniques (contrast‑enhanced ultrasound‑targeted, micro‑ultrasound/PRI‑MUS, fluorescence spectroscopy spectral analysis, and superb microvascular imaging) experimental/investigational and not covered for other indications. Key requirements: covered procedures require abnormal PSA and/or DRE (MRI‑guided diagnosis also requires prior biopsy), life expectancy >5 years for surveillance, repeat abnormal DRE/rising PSA or suspicious MRI and a repeat biopsy that will affect treatment; CPTs 55706/55700/G0416 are covered if criteria met, the DNA specimen provenance assay is not separately reimbursed, and screening code Z12.5 is not covered.