A prostate biopsy is a diagnostic procedure where small tissue samples are collected from the prostate gland to be examined for signs of cancer or other conditions. Medicare generally covers this procedure when a physician determines it is medically necessary, typically following abnormal results from initial screenings like a Prostate-Specific Antigen (PSA) blood test or a Digital Rectal Exam (DRE). Coverage depends on which part of the program is covering the service and the location where the biopsy is performed. The patient’s ultimate financial obligation is a combination of deductibles and coinsurance payments.
How Original Medicare Covers a Prostate Biopsy
The vast majority of prostate biopsies are performed on an outpatient basis, meaning coverage falls under Medicare Part B, the medical insurance portion of Original Medicare. This coverage is triggered when the procedure is ordered by a doctor to diagnose or treat a specific medical condition, fulfilling the requirement for “medical necessity.” Medicare Part B covers the services of the physician, the supplies used, and the facility costs associated with the outpatient procedure.
Medicare Part A, which covers inpatient hospital services, would only be involved if the biopsy led to a rare inpatient hospital stay due to complications. If an inpatient admission becomes necessary, Part A would cover the hospital stay, subject to its own separate deductible and coinsurance schedule.
Patient Financial Responsibility: Deductibles and Coinsurance
Medicare’s payment for a prostate biopsy is based on the Medicare-approved amount for the service. Before Medicare begins paying its share, the patient must first satisfy the annual Part B deductible. For 2025, this deductible is set at $257, and it must be met each calendar year before Part B coverage begins.
Once the deductible has been satisfied, Medicare Part B pays 80% of the Medicare-approved amount for the procedure. The patient is then responsible for the remaining 20% coinsurance.
For example, if the total Medicare-approved amount for the biopsy procedure and associated services is $1,750, Medicare would pay $1,400 (80% of $1,750). The patient’s coinsurance responsibility would be $350 (20% of $1,750), plus any portion of the annual deductible that had not yet been met. The patient’s actual payment can fluctuate depending on whether the physician accepts “assignment,” meaning they agree to accept the Medicare-approved amount as full payment.
Cost Variations Based on Setting and Plan Type
The total cost of a prostate biopsy, and therefore the patient’s 20% coinsurance, can vary significantly based on where the procedure is performed. Biopsies performed in a physician’s office setting are typically the least costly, averaging around $1,750 for the episode of care. Conversely, the same procedure performed in an outpatient hospital setting is more costly, averaging about $2,730, largely due to higher facility fees.
Patients enrolled in a Medicare Advantage (Part C) plan experience a different financial structure. These private plans must cover the same medically necessary services as Original Medicare, including the prostate biopsy, but they replace the 20% coinsurance with their own cost-sharing rules. This may take the form of a fixed copayment or a different coinsurance percentage, which can vary from plan to plan.
A patient who has a Medigap (Medicare Supplement Insurance) policy will have their out-of-pocket costs significantly reduced or eliminated. Most Medigap plans are designed to pay the 20% coinsurance amount that the patient is responsible for under Original Medicare. This supplemental coverage shields the beneficiary from the standard 20% cost-share, providing more predictable and lower overall expenses for the procedure.