Does Medicare cover 4Kscore test?

Medicare covers a 4Kscore® test in specific circumstances when it is deemed medically necessary. A 4Kscore® is covered by Medicare Part B after an abnormal result is returned from the common prostate cancer screenings. The 4Kscore® test Medicare coverage may have out-of-pocket expenses, but Medicare Supplement can help cover coinsurance and deductibles.

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UPDATED: Jun 1, 2022

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The Highlights

  • Medicare will cover the 4Kscore® test for prostate cancer under Medicare Part B
  • The test must be deemed medically necessary in order to be covered by Medicare
  • Prior prostate cancer screenings, including blood tests and a digital rectal exam, will be done before a 4Kscore®

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.

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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.

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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.

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.

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