PSA (Prostate Specific Antigen) (CPT 84153)
Medicare Rate vs. Lab Charges
Medicare pays $18.73 for this test. Labs commonly charge $65.00–$240.00. That's a 247%–1181% markup above what Medicare pays.
What This Test Is
PSA measures a protein produced by the prostate. Elevated PSA can indicate prostate cancer, benign prostate hyperplasia (BPH), or prostatitis. It's commonly used for cancer screening in men over 50, though its utility is debated. Medicare covers it for men with symptoms or diagnosed prostate disease.
Medicare Rate vs. Lab Charges
| Medicare Allowable Rate | $18.73 |
| Typical Lab Charge Range | $65.00–$240.00 |
| Average Markup Above Medicare | 247%–1181% |
Does Medicare Cover This Test?
Yes, Medicare Part B covers PSA for men with prostate symptoms or diagnosed prostate disease. Routine screening may be covered under certain circumstances but is not universally covered.
Common Reasons for Denial
- Routine screening in asymptomatic men without prostate disease history
- Screening without shared decision-making or documented medical necessity
- Tested too frequently without clinical change
- No diagnosis code indicating prostate disease or symptoms
- Age-based screening alone without clear indication
What To Do If You're Overcharged
If you received a lab bill that seems unusually high compared to Medicare rates:
- Check your Explanation of Benefits (EOB) from Medicare or your insurance to see what should have been paid.
- Request an itemized bill from the lab showing all charges.
- Compare to GougeStop rates for your area to see if the charge is reasonable.
- Contact the lab's billing department to dispute erroneous charges or negotiate a lower rate.
- File an appeal with Medicare if a claim was incorrectly denied.
Frequently Asked Questions
A: That's debated. Organizations differ on recommendations. Talk to your doctor about risks/benefits, especially if you have family history of prostate cancer.
A: For men with prostate symptoms or diagnosed disease, yes. For asymptomatic men as pure screening, it may not be covered—check your policy.
A: Elevated PSA doesn't always mean cancer. Your doctor may repeat the test, do a digital rectal exam, or refer to a urologist for further evaluation.