Question: We have an elderly patient who my doctor doesn’t want to subject to a prostate biopsy. The patient shows signs of bone metastases and very high PSA. My doctor wants to start Lupron, but I explained to him that Medicare will only cover Lupron for a diagnosis of prostate cancer. My doctor wants to know if he has to have a tissue diagnosis of 185 in order to call it prostate cancer. What is the rule?
New York Subscriber
Answer: As long as your physician can make a clinical diagnosis of carcinoma of the prostate (185, Malignant neoplasm of prostate), you may bill for the Lupron with a diagnosis of prostate cancer.
A biopsy is not necessary to give a diagnosis of cancer if the symptoms and clinical findings lead to the clinical cancer diagnosis.
