CommercialCoverageHigh impact
Magnetic Resonance Imaging (MRI) of the Prostate 6.01.46
Excellus BlueCross BlueShield·Urology, Radiology, Oncology·Radiology (x-rays) & Imaging
Effective date
May 15, 2026
We identified it
Jun 20, 2026
Summary
Excellus BlueCross BlueShield has updated their MRI prostate policy (6.01.46) effective May 15, 2026, establishing new medical necessity criteria for prostate MRI based on age, PSA levels, risk factors, and clinical indications. The policy covers suspected prostate cancer, staging, restaging, and active surveillance scenarios with specific requirements for each indication.
Action Required
Before May 15, 2026: Clinical and billing teams must review all prostate MRI orders against the new medical necessity criteria. Update prior authorization workflows to verify patients meet age requirements (40-75 for high-risk, 45-75 for standard risk, >75 with higher PSA thresholds), PSA levels, family history, and clinical indications. Ensure documentation includes recent PSA values, DRE findings, and risk stratification per NCCN guidelines. Claims not meeting the specified criteria will likely be denied.