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Magnetic Resonance Imaging (MRI) of the Prostate 6.01.46
Excellus BlueCross BlueShield·Urology, Radiology, Oncology·Radiology (x-rays) & Imaging
Effective date
May 15, 2026
We identified it
Jul 16, 2026
Summary
Excellus BlueCross BlueShield has released a comprehensive new policy (6.01.46, effective May 15, 2026) establishing detailed medical necessity criteria for prostate MRI across five clinical scenarios: suspected prostate cancer, initial work-up/staging, restaging/recurrence, and active surveillance follow-up. The policy introduces specific age, PSA, risk stratification, and clinical history requirements that must be met for coverage. Notably, serial MRIs for monitoring elevated PSA alone are NOT medically necessary, and MR guidance for needle placement is not covered.
Action Required
By May 15, 2026: Billing and clinical teams must immediately implement new prior authorization requirements for all prostate MRI requests. (1) Update billing software and pre-authorization templates to capture: patient age, current PSA value (required per policy guideline), clinical history (prior biopsies, DRE findings, family history), risk stratification category (very low/low/intermediate/high/very high), and treatment history. (2) Clinical staff must verify ALL orders meet specific indications in Section I-V before submission—requests lacking required documentation will be denied. (3) Flag and REJECT claims for: serial MRIs used only for PSA monitoring (per Section VI), MR guidance for biopsy needle placement (Section II), or requests outside defined age/PSA/clinical criteria. (4) Train providers that imaging must align with NCCN risk stratification (referenced in Section III and guidelines) and that mpMRI frequency for active surveillance cannot exceed every 12 months unless clinically justified (Section V). (5) Update encounter forms and ordering workflows to prompt for specific data elements (age, PSA date/value, DRE findings, biopsy history, risk group classification). Failure to obtain authorization with required clinical criteria will result in automatic denials. This is a Excellus BlueCross BlueShield product-specific policy effective immediately upon the stated date.