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Molecular Biomarkers for Prostate Cancer Risk Stratification - Medicare Advantage (Revised)
Act
by Sep 30, 2026
Effective date
Oct 1, 2026
Identified
Oct 2, 2026
Summary
This is a comprehensive Medicare Advantage coverage policy for molecular biomarker tests used in prostate cancer risk stratification (effective 10/1/2026). The policy establishes coverage criteria for tests like ArteraAI, EpiSwitch, IsoPSA, MyProstateScore 2.0, ProMark, and ProsTAV, with coverage determinations based on MAC-specific LCDs/LCAs that vary by geographic jurisdiction. Billing teams must identify the correct MAC jurisdiction and apply the corresponding LCD requirements for each test ordered.
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What to do
by Sep 30, 2026 · 6 steps
01Billing team must map all prostate biomarker test orders to the correct Medicare Administrative Contractor (MAC) jurisdiction based on patient location.
02Review the 9 MAC jurisdictions listed (J5, J8, J6, JK, J15, JE, JF, JH, JL, JJ, JM, JN) and obtain the corresponding LCD/LCA documents for your geographic region.
03Update billing system rules to require prior authorization verification through the applicable MAC's LCD before processing claims for ArteraAI Prostate Test, EpiSwitch PSE, IsoPSA, MyProstateScore 2.0, Percent-free PSA, ProMark, and ProsTAV.
04Providers must document medical necessity per MAC-specific LCD criteria.
05Failure to verify coverage through the correct MAC LCD will result in claim denials.
06Reference the specific LCD document IDs and LCA article IDs listed in the policy for your region's MAC contractor.
Original notice
Molecular Biomarkers for Prostate Cancer Risk Stratification - Medicare Advantage (Revised)
mcp.humana.com · Always check the source before changing claims.
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