Does Medicare cover the 4Kscore test?

Does Medicare cover a 4Kscore® test? Medicare covers a 4Kscore® test for patients who meet specific criteria. A 4Kscore® test is a diagnostic tool for prostate cancer that is used after there has been an abnormal prostate-specific antigen (PSA) or digital rectal exam (DRE) test result. Not all health insurance plans will cover this test, and as with Medicare, there are often specific requirements. There may be an out-of-pocket cost associated with the test. Medicare Supplement or Medicare Advantage plans can help to cover some of these costs.

If you’re looking to reduce your out-of-pocket expenses for a 4Kscore® test through Medicare, enter your ZIP code to compare rates on supplemental and Medicare Advantage options.

Does Medicare cover the 4Kscore® test?

According to Medicare.gov, prostate cancer screenings are covered by Medicare. There are two common screenings that are covered as initial steps towards diagnosing prostate cancer. An abnormal finding on either of these screenings can warrant the use of a 4Kscore® to get further information. Medicare coverage for the test was approved in November 2019.

The two common screenings are:

• Prostate-specific antigen (PSA)
• Digital rectal exam (DRE)

Both of these are covered by Medicare on an annual basis. While the PSA test, a blood test, is covered in full, the DRE has a 20 percent coinsurance and your Part B deductible applies.

Medicare will cover the 4Kscore® test when it is deemed to be medically necessary, based on specific findings in previous tests and only in men over the age of 45.

What is the cost of a 4Kscore® test with Medicare?

Medicare doesn’t list the test on its website, which may be due to the fact that it’s a relatively new test. As a diagnostic test, the 4Kscore® test will likely be subject to Part B coinsurance of 20 percent and to the Part B deductible as well.

If you have a Medicare Advantage plan, you will need to check with your provider to find out what is covered and what your out-of-pocket costs will be. For those with Original Medicare, a Medigap (Medicare Supplement) plan can cover some or all of the coinsurance and deductible amounts to reduce the out-of-pocket expense.

What does 4Kscore measure?

The 4Kscore takes the results of four blood tests and factors in a man’s age, DRE results, and if he had a prior biopsy. A number is created. It reflects the percentage likelihood that if that patient had a biopsy, an aggressive prostate cancer would be found.

Which men need the test?

All men should follow national guidelines for prostate cancer screening, based on age, race, family history and other risk factors. The digital rectal exam (DRE) and the PSA test remain the first two steps of screening.

What does my prostate do?

The prostate is beneath the bladder and in front of the rectum. It’s a walnut-shaped gland that surrounds part of the urethra. (That’s the tube that carries pee and semen out of the penis ). Here’s what it does:

It produces fluid for semen, which includes sperm produced in the testicles.

It prevents urine from being included during ejaculation.

What’s the problem with a biopsy?

During a core needle biopsy, a thin, hollow needle is used to remove several small pieces of prostate tissue. The procedure can cause anxiety, pain, bleeding and/or infection in some patients. The core needle biopsy is still standard procedure for men deemed high-risk. But the 4Kscore test provides a way to weed out men who may have far less aggressive prostate cancers.

The 4Kscore test is supposed to reduce unnecessary biopsies in men being considered for biopsy of the prostate for potential cancer.

Case Studies: Exploring Medicare Coverage on the 4Kscore Test

Case Study 1: John’s Experience With Medicare and the 4Kscore Test

John, a 65-year-old Medicare beneficiary, was concerned about his prostate health and wanted to undergo the 4Kscore test—a diagnostic tool used to assess the risk of aggressive prostate cancer. However, he was unsure if Medicare would cover the test. John approached his primary care physician (PCP) to inquire about Medicare coverage for the 4Kscore test.

Although disappointed, John decided to pursue alternative diagnostic options for prostate cancer recommended by his PCP, which were covered by Medicare. He appreciated the clarity provided by Medicare and understood the importance of evidence-based coverage decisions to ensure effective and appropriate healthcare services.

Case Study 2: Sarah’s Successful Appeal for Medicare Coverage of the 4Kscore Test

Sarah, a 62-year-old Medicare beneficiary, had a family history of prostate cancer and wished to undergo the 4Kscore test to assess her risk. She understood that Medicare might not cover the test but was determined to explore all available options. Sarah consulted her urologist, who had experience dealing with Medicare coverage appeals.

Sarah was relieved that her appeal was successful, as it allowed her to undergo the 4Kscore test without incurring substantial out-of-pocket expenses. Her case highlighted the importance of gathering robust evidence and engaging healthcare professionals experienced in navigating Medicare coverage appeals.

Case Study 3: James’ Exploration of Private Insurance Options for the 4Kscore Test

James, a 58-year-old individual approaching Medicare eligibility, wanted to explore private insurance coverage options for the 4Kscore test. He understood that Medicare might not cover the test, and he wished to secure coverage through a private insurance plan before transitioning to Medicare.

By proactively exploring private insurance options, James ensured that he could undergo the 4Kscore test with minimal financial burden before transitioning to Medicare.

His experience highlighted the importance of thoroughly reviewing insurance plans and considering individual needs when seeking coverage for specific diagnostic tests that may not be covered by government healthcare programs like Medicare.

Does Medicare cover a 4Kscore® test? The Bottom Line

Medicare will cover a 4Kscore® for prostate cancer when it is found to be medically necessary based on the results of previous screenings. It is covered for men 45 or older who meet the criteria. There may be out-of-pocket costs for the test.

Data from two prospective clinical studies involving approximately 1,500 patients in urology centers in the U.S. demonstrated that the 4Kscore® test had 94% sensitivity and 95% Negative Predictive Value for detecting aggressive prostate cancer.

To compare rates for Medicare Advantage or find a Medicare Supplement plan that will cover your expenses for a 4Kscore® test, enter your ZIP code now.