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During a prostate biopsy, a doctor takes small samples of tissue from your prostate to screen for cancer.
If the results of a screening (a blood test or a digital rectal exam) indicate that you may have prostate cancer, your doctor will order a Magnetic Resonance Imaging, often referred to as an MRI.
If you need to get a prostrate biopsy, then you are likely wondering “Does Medicare cover MRI Guided Prostate Biopsy?” In this article, we answer the question in clear, plain English.
Does Medicare Cover MRI Guided Prostate Biopsy?
The short answer is yes; Medicare will cover the cost of treatment for MRI-guided prostate biopsy. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met in order for Medicare to pay for your MRI-guided prostate biopsy.
Let’s take a look at what conditions must apply, so you know what to expect.
Original Medicare Coverage of MRI Guided Prostate Biopsy
Medicare Part A and Part B provides coverage for MRI-guided prostate biopsy. Original Medicare provides coverage for your MRI-guided prostate biopsy if it is considered medically necessary.
This means that your healthcare provider must first order the operation for Original Medicare to provide coverage.
How Does Original Medicare Provide This Coverage?
Original Medicare provides coverage for MRI-guided prostate biopsy similar to how they provide coverage for other types of biopsies.
Coverage for MRI-guided prostate biopsy is provided by Medicare Part A if your MRI-guided prostate biopsy takes place in an inpatient setting. Medicare Part A will cover 100 percent of the costs of hospital stays for up to 60 days.
On the other hand, most of the time, coverage for MRI-guided prostate biopsy is provided by Medicare Part B. This is because they often take place in an outpatient setting.
Once approved, Medicare Part B covers 80 percent of the costs of MRI-guided prostate biopsy. You will pay for the remaining 20 percent.
Other Prostate Tests Covered by Original Medicare
If you are 50 or older, Original Medicare provides coverage for an annual prostate-specific antigen test to screen for prostate cancer.
When the results of your screening show higher than normal levels of the antigen, your healthcare provider may order a biopsy to find out whether there are any present cancer cells.
Original Medicare provides coverage for prostate biopsy similar to how they provide coverage for other types of biopsies.
Medicare Advantage Plans Coverage of MRI Guided Prostate Biopsy
Medicare Advantage plans (Medicare Part C) also provide coverage for MRI-guided prostate biopsy.
The rule to know here is that Medicare Advantage, or Part C, must cover everything that Original Medicare covers.
However, these plans will also offer some additional benefits. These additional benefits might include prescription drug coverage and access to other health and wellness programs which could help with regards to recovery.
But what a plan covers and how much the out-of-pocket costs vary depending on your plan’s specifics. A common factor that can affect your plan is the area in which you live.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.
Additional Info on Medicare Coverage
This article is part of our series on “What does Medicare cover?”
Also, you can check out other articles in this series including: Does Medicare Cover Hair Loss Treatment?