Does Medicare Cover a Prostate Biopsy?

A prostate biopsy is a common diagnostic procedure utilized when concerns arise about prostate health, often following abnormal findings from a prostate-specific antigen (PSA) blood test or a digital rectal exam (DRE). Understanding how Medicare covers this procedure is important for beneficiaries. This article aims to clarify Medicare’s role in covering prostate biopsies, outlining typical coverage, potential patient costs, and the functions of Medicare Advantage and Medigap plans.

Medicare Coverage for Prostate Biopsies

Medicare generally provides coverage for medically necessary prostate biopsies. Most procedures are performed in an outpatient setting, so Medicare Part B typically covers the associated costs. Part B covers medical services, including professional fees for the urologist, facility charges (such as an outpatient clinic or hospital outpatient department), and pathology services for tissue analysis.

Coverage is contingent upon medical necessity, established by a healthcare provider based on clinical indicators like elevated PSA levels or suspicious digital rectal exam findings. In rare cases requiring an inpatient hospital stay, Medicare Part A covers hospital expenses. However, prostate biopsies are almost exclusively outpatient procedures.

Patient Costs and Out-of-Pocket Expenses

Beneficiaries with Original Medicare (Parts A and B) will incur certain out-of-pocket expenses for a prostate biopsy. For Part B services, beneficiaries are responsible for an annual deductible. In 2025, the Medicare Part B deductible is $257. After this deductible is met, Medicare Part B typically covers 80% of the Medicare-approved amount for the services, leaving the beneficiary responsible for the remaining 20% coinsurance. This 20% coinsurance applies to the doctor’s services, outpatient facility fees, and pathology services.

If a prostate biopsy involves a rare inpatient hospital stay covered by Medicare Part A, a separate deductible applies. The Medicare Part A deductible in 2025 is $1,676 per benefit period. If the inpatient stay extends beyond 60 days in a benefit period, daily coinsurance amounts would also apply. Original Medicare does not have an annual limit on out-of-pocket costs, meaning the 20% coinsurance can accumulate without a cap.

How Medicare Advantage Plans Cover Prostate Biopsies

Medicare Advantage Plans, also known as Part C, are offered by private insurance companies. These plans are an alternative to Original Medicare, providing all Part A and Part B benefits, often with additional benefits such as prescription drug coverage. When it comes to prostate biopsies, Medicare Advantage Plans are required to cover at least the same medically necessary services as Original Medicare.

While the coverage scope is similar, the costs associated with a prostate biopsy under a Medicare Advantage Plan can differ significantly from Original Medicare. These plans may have their own deductibles, copayments, or coinsurance structures. Many Medicare Advantage Plans operate with network restrictions, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), which can influence a beneficiary’s choice of healthcare providers and facilities. Prior authorization for procedures like a prostate biopsy is common, requiring plan approval before the service. Beneficiaries should review their specific plan’s details to understand their financial responsibilities and any procedural requirements.

The Role of Medigap in Coverage

Medigap (Medicare Supplement Insurance) policies are sold by private companies to help Original Medicare beneficiaries cover out-of-pocket costs. These policies work in conjunction with Original Medicare, meaning they do not replace Part A or Part B benefits. Instead, Medigap plans aim to fill the “gaps” in Original Medicare coverage, providing financial assistance for deductibles, coinsurance, and copayments.

For a prostate biopsy, a Medigap policy can significantly reduce a beneficiary’s financial burden. These plans can cover the Medicare Part B deductible ($257 in 2025) and the 20% Part B coinsurance for the biopsy, facility fees, and pathology services. If a rare inpatient stay were to occur, Medigap plans could also cover the Medicare Part A deductible and any applicable coinsurance. Different Medigap plans, such as Plan G or Plan N, offer varying levels of coverage for these out-of-pocket costs. Medigap policies work with Original Medicare and cannot be used with Medicare Advantage Plans.