Prostate Biopsy (CPB 0698, reviewed 2026-10-20)

Verify current policy applicability with Aetna: The prostate biopsy policy was reviewed on 2026-10-20, but no future effective date is stated in the source document. Billing team should: (1) Confirm whether this reviewed policy replaces a prior version and when the transition occurred; (2) Update billing system edits to enforce medical necessity criteria for covered CPT codes 55705–55715, 55707–55714 (only when diagnostic criteria are met: persistently elevated/rising PSA, abnormal DRE, suspicious imaging findings per PI-RADS scoring, or prior negative biopsy with clinical suspicion); (3) Implement claim denial logic for experimental procedures (0443T, 0898T, micro-ultrasound, contrast-enhanced ultrasound, liquid biopsy for methylation, AI-based mapping software); (4) Configure billing system to treat the Know Error® DNA Specimen Provenance Assay as integral to the biopsy procedure—not separately billable; (5) Retain claim processing rules that Z12.5 (prostate cancer screening encounter) is not covered. Contact Aetna directly to confirm implementation timeline and whether prior authorization is required for covered codes.