At my annual "wellness" checkups in 2024 and 2025, my primary care doc ordered PSA tests, because I was presenting with various urinary symptoms. Medicare paid in 2024 but did not pay in 2025.

Sometimes I go through a dispute process just to get a better understanding of how the system works, rather than just pay. (I think the testing company wanted $65).

I called the company that did the test. I called the doc's office. I visited the doc's office with a statement from the testing company that said they probably hadn't submitted the bill for it with the right code.

By the time I decided to call Medicare to dispute this with a person, I had an MRI result in hand, showing PI-RADs 5 "highly likely clinically significant cancer" in one large mass and several other places in my prostate. This meant nothing to the person I talked to, so it seemed. The Medicare rep agreed with me when I described my understanding of current Medicare policy as - they will pay for one PSA test per year as a screen.

Without missing a beat, she explained that the doc had not convinced them that this PSA test was "medically necessary" so they didn't have to pay. What do you think a test approved for use as a yearly screen is, I argued, medically unnecessary? I pointed out that this PSA test led me to get an MRI that showed I had "highly likely clinically significant cancer". Medicare, according to this rep, didn't have to pay.

I hung up. A few weeks later, I was about to pay the testing company when I discovered that they had decided I didn't owe them anything because Medicare coughed up the payment.

There is a lot of weirdness around testing.

Because the 2024 test was 3 and the 2025 test was 5 the primary care doc sent me to a urologist. I wasn't that interested in acting on what he called this "jump up" in PSA results and turned down his advice I get a biopsy. I agreed to repeat the test in a few months. The repeated PSA showed the level was increasing. I agreed to an MRI. Suddenly I was down the prostate cancer rabbit hole. Etc.

What caused me to delay looking into this was this controversy around PSA testing. I had heard that the US screening guideline committee in 2012 had recommended against routine PSA screening. I wondered: if the info they were getting from a test was any good, they wouldn't be recommending against it. Docs wouldn't be told: don't do it.

The problem is what to do when the result comes in. There's nothing wrong with the test. Its one of the best tests for any cancer that is available.

The problem is patients freak out when they find out they have "cancer", and doctors respond with treatments, and all the treatments have some toxicity. Not all of the detected cancers would have caused any problem to the patient during their lifetime, especially when compared to the toxic side effects of the treatments. Some of the detected cancers will kill.

Everyone involved is learning. I wish I had looked into this controversy over PSA testing and concluded it made sense to get tested every once in a while. But it took a diagnosis, cT3b "high risk" prostate cancer, to wake me up.