Am I eligible for the prostate cancer mpMRI rebate?
by Tom White, July 29, 2020

Since July 1 2018 Medicare has been providing a rebate of $450 for a Multi Parametric MRI (mpMRI) of the prostate. This is for both diagnosis and monitoring of a previous diagnosis.

However, not everyone is eligible, and even if you qualify, you may still end up paying an out of pocket fee. If you are searching for a place to have your MRI done without paying an out of pocket. Please send an email to support@maxwellplus.com; we may be able to help.

Below we have stepped through when patients are and are not eligible for the rebate.

MRI rebate for diagnosis

For diagnostic purposes (you have not had a previous positive diagnosis), the rules surrounding being eligible for the rebate are as follows.

First condition: it must have been requested by a Urologist, Radiation Oncologist or Medical Oncologist. You cannot receive the rebate if your GP requested the MRI.

Second condition: the patient must be “suspected of having prostate cancer.” Accepted definitions of this are:

For those under the age of 70 years

  1. A digital rectal examination (DRE) which is suspicious for prostate cancer; or
  2. At least two prostate specific antigen (PSA) tests performed within an interval of 1- 3 months are greater than 3.0 ng/ml, and the free/total PSA ratio is less than 25% or the repeat PSA exceeds 5.5 ng/ml;or 
  3. If a family history is present (see below for definition). At least two PSA tests performed within an interval of 1- 3 months are greater than 2.0 ng/ml, and the free/total PSA ratio is less than 25%; or

For those 70 years or older

  1. in a person aged 70 years or older, at least two PSA tests performed within an interval of 1- 3 months are greater than 5.5ng/ml and the free/total PSA ratio is less than 25%.

Third condition: The patient has not had a rebated prostate mpMRI within the past 12 months.

Relevant family history is a first degree relative with prostate cancer or suspected of carrying a BRCA 1, BRCA 2 mutation. First degree is brother, father, or son.

Example 1

55-year-old male;
No family history;
PSA in January = 2.2 ng/mL;
PSA in March = 3.5 ng/mL and 23% Free to Total Ratio;
Normal DRE;

NOT ELIGIBLE 

With no positive family history, both PSAs must be above 3.0 ng/mL. It might be beneficial for this patient to have another blood test in April.

Example 2

55-year-old male;
No family history;
PSA in January = 2.2 ng/mL;
PSA in March = 3.5 ng/mL and 23% Free to Total Ratio;
Abnormal DRE;

ELIGIBLE 

This patient would be eligible due to the suspicious digital rectal exam.

Example 3

55-year-old male;
Positive family history (brother has been diagnosed);
PSA in January = 2.2 ng/mL;
PSA in March = 3.5 ng/mL and 23% Free to Total Ratio;
Normal DRE;

ELIGIBLE 

This patient would be eligible due to:

  • positive family history AND;
  • both PSA levels being above 2.0 ng/mL AND;
  • the Free to Total Ratio is below 25%;

MRI rebate for monitoring a positive diagnosis

First condition: it must have been requested by a Urologist, Radiation Oncologist or Medical Oncologist. You cannot receive the rebate if your GP requested the MRI.

Second condition: The patient has a positive diagnois and satisfies the below two points:

  1. the patient is under active surveillance following a confirmed diagnosis of prostate cancer by biopsy histopathology; and
  2. the patient is not planning or undergoing treatment for prostate cancer

If you have any questions please send us an email to support@maxwellplus.com.