Local Coverage Determination (LCD)

ProMark® Risk Score


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Proposed LCD
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Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
Original ICD-9 LCD ID
Not Applicable
LCD Title
ProMark® Risk Score
Proposed LCD in Comment Period
Source Proposed LCD
Original Effective Date
For services performed on or after 07/17/2017
Revision Effective Date
For services performed on or after 12/28/2023
Revision Ending Date
Retirement Date
Notice Period Start Date
Notice Period End Date
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Issue Description

Minor grammatical changes made throughout. Updated accession dates for reference #3 and #4. No changes in coverage.

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

42 CFR §410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.

CMS Internet Online Manual Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15, Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests, §80.1.1 Certification Changes.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

This Contractor will provide limited coverage for the ProMark® (Metamark Genetics) to help determine which patients with early stage, needle biopsy proven prostate cancer can be conservatively managed rather than treated with definitive surgery or radiation therapy.

Summary of Evidence

In 2014, nearly 233,000 men in the US will be diagnosed with prostate cancer, which accounts for 14% of all new cancer diagnosis. More than 29,000 men will die from this disease representing 5% of all cancer deaths. Gratefully 98.9% of men are surviving at 5 years.3

Many individuals do not need treatment for their prostate cancer in as much as their prognosis is excellent even without treatment. However, physicians and patients struggle to know who can safely be observed versus the subgroup that needs more aggressive treatment to achieve cure, and recognize that definitive treatment for localized prostate cancer can have lifelong morbidities.5,8

Traditionally, clinicopathologic characteristics are utilized to determine risk and subsequent treatment. Several nomograms have been introduced to try to determine who is at risk of developing metastatic disease and who, if treated early, could avoid this outcome. A representative nomogram taken from the National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA), divides early prostate cancer into several groups based initially on life expectancy, with a second stratification using clinical exam, reassessment of life expectancy, biopsy (Gleason score), prostate-specific antigen (PSA) and imaging after 5 years.

These groups are detailed below:

  Risk Category
  Very Low Low Intermediate High
Clinicopathologic Findings


  • Gleason score ≤ 6
  • PSA ≤ 10 ng/mL
  • < 3 prostate
    cores with tumor
  • ≤ 50% tumor in
    any core AND
  • PSA density of <
    0.15 ng/mL/g
  • T1-T2a
  • Gleason
    score ≤ 6 Gleason grade group 1
  • PSA ≤ 10

T2b-T2c OR

  • Gleason score 3+4=7/Gleason grade group 2


  • Gleason score 4+3=7/Gleason grade group 3


  • PSA 10-20

T3a OR

  • Gleason
    Score 8/Gleason grade group 4


  • Gleason score 9-10/Gleason grade group 5


  • PSA > 20
Treatment Options        
≥ 20 y life


  • RT or Brachy
  • RP (± LND)
≥ 10 y life
  • Active


  • RT or Brachy
  • RP (± LND)
RP (± LND)
  • RT or Brachy
    ± Adj Horm

RT + Adj

  • RT +
  • RP + LND
    ± RT, ADT
< 10 y life
Observation Observation RT or Brachy
± Adj Horm
  • Observation

Table 1: NCCN 2017.V2 - Localized Prostate Cancer Risk Stratification and Treatment
(PSA- Prostate Specific Antigen; RT- Radiation Therapy; RP – Radical Prostatectomy; LND – lymph node dissection; Adj Horm -Adjuvant Androgen Deprivation).

Use of these stratification and treatment approaches has led to high cure rates for early stage prostate cancer, yet it is widely accepted that many men are over-treated to achieve this cure rate. In the PIVOT trial9 men with early prostate cancer, initially randomized to radical prostatectomy or observation, showed that over 12 years there was no difference in absolute mortality between the groups. However, this study was hampered by several factors including:

  • Only 731 of 5023 eligible patients chose to participate in the study based on randomization criteria.
  • In the group randomized to RP: only 85% of the men received definitively therapy (79% surgery; 6%other).
  • In the observational group: 10% of the observation group received RP initially and additional 20% eventual received definitive treatment.
  • Despite broad inclusion criteria, > 50% of patients had a PSA of <10 (median PSA of 7) and had biopsy proven T1c disease. Although there were a significant number of patients with Gleason score ≥7 (25%), 40% of men were classified initially as being low risk; and 30% were intermediate.

Although subgroups were small, it appears that high-risk groups (including those with PSA > 10) benefitted from RP. Furthermore, there was a trend for the intermediate risk patients to benefit from RP as well. The small number of patients willing to enter the study, and the high rate of crossover (both initially and subsequently) demonstrates the difficulty of doing observation trials in the United States.

Although there is early data that may suggest that some patients with intermediate risk prostate cancer could potentially be considered for active surveillance (AS) (Gleason Score 3+4 = 7, PSA < 10), the NCCN and other mainstream groups still do not recommend this approach, with the NCCN stating, “Active surveillance of intermediate and high-risk clinically localized cancers is not recommended in patients with life expectancy ≥10 years as a category 1 recommendation. The shortcomings in the current system have driven the development of emerging biomarker-based tools for assessing risk.”

ProMark® Test
Test Description
ProMark® is a biopsy-based prostate cancer prognostic test that utilizes an automated, quantitative protein-based multiplex immunofluorescent in situ imaging platform to evaluate standard formalin-fixed, paraffin-embedded (FFPE) prostate tissue to differentiate indolent from aggressive prostate cancer.1,6,7 The assay measures the signal intensity of 8 protein biomarkers (i.e., CUL2, DERL1, FUS, HSPA9, PDSS2, pS6, SMAD4 and YBX1) in tumor and benign prostate glands on FFPE biopsy tissue sections to generate an algorithmically derived risk score indicating the likelihood of having high-risk disease. Unlike deoxyribonucleic acid (DNA)/ribonucleic acid (RNA) based tests that require biopsy tissue to be homogenized prior to analysis, ProMark® technology allows for analysis of proteins directly from the cancerous regions of interest. The test has shown the ability to predict prostate cancer aggressiveness regardless from which region the prostate biopsy was taken, a key feature and benefit given the considerable heterogeneity that exists in biopsied tissue.6

Test Development and Performance
ProMark® was validated through a series of studies from initial proof of concept to final marker lock-down and validation trials involving more than 1200 patients in a 3-phase program.

The assay development study was a non-interventional and retrospective study devised to define the best marker subset from those candidate proteins previously shown to correlate with both prostate pathology aggressiveness and lethal outcome. The study goal was to define a model able to distinguish between prostate pathology usually recommended for active surveillance ("GS 6"; surgical Gleason 3+3 and ≤T3a) versus those more likely to require prostatectomy ("non-GS 6"; surgical Gleason ≥3+4 or non-localized >T3a or N or M). This GS 6 versus non-GS 6 definition was based on studies showing that tumors with surgical Gleason 3+3 at prostatectomy do not metastasize. A logistic regression model was trained on the training set, and risk scores were obtained for samples in both the training and testing sets. The final marker coefficients were used in a logistic regression model for calculation of the risk score, a continuous scale from 0 to 1, which estimated the likelihood of "non-GS6" pathology.

The validation study cohort (N=276) was separate and independent from the assay development cohort, and comprised biopsy samples with matched prostatectomy specimens. It was a non-interventional, blinded, prospectively designed, retrospectively collected clinical study to predict prostate pathology on its own and relative to current systems for patient risk categorization. A risk score was generated for each sample. Inclusion criteria were biopsies with a centralized Gleason score 3+3 or 3+4 (biopsies with discordant grading by two expert pathologists of 3+4 and 4+3 were included as well), and matched prostatectomy with pathologic TNM staging, PSA level, and resulting surgical Gleason score. Central review was performed on biopsies, whereas for prostatectomies the investigators relied on the original pathology annotation, due to practical challenges in accessing all the different locations where these had been conducted; however, all prostatectomy pathology annotation was done according to new International Society of Urological Pathology (ISUP) classification. Matched prostatectomy samples with annotated surgical Gleason scores ultimately classified the tumor as "favorable" or "non-favorable" for the purposes of evaluating assay results. Sample sizes were statistically designed, with power greater than 95% for both cohorts. Receiver operating characteristics (ROC) and corresponding area under the curves (AUC) determined for the 8-biomarker risk score quantitatively evaluated performance of the assay.

Favorable (Gleason ≤3+4 and organ-confined disease (≤T2)) versus non-favorable (Gleason ≥4+3 or non-organ-confined disease (T3a, T3b, N, or M)) pathology were co-primary endpoints in the validation study. The other co-primary endpoints were "GS6" pathology (Gleason 3+3 and localized disease (≤T3a)) versus "non-GS 6" pathology (Gleason ≥3+4 or non-localized disease (T3b, N, or M)). The analysis for "favorable" pathology yielded an AUC of 0.68 with 95% CI, 0.61-0.74. The associated P value was <0.0001, with an OR for risk score of 20.9 per unit change. "GS 6" pathology yielded an AUC of 0.65 with 95% CI, 0.58-0.72. The associated P value was <0.0001, with an OR for risk score of 12.6 per unit change.

The intended use of ProMark® is to categorize a patient to favorable versus non-favorable disease pathology based on his risk score on the specificity curve (not provided). The positive predictive value (PPV) for favorable pathology, at a risk score of ≤0.33, was 83.6% (specificity, 90%). Conversely, at a risk score of >0.80, 76.9% had non-favorable disease (i.e., only 23.1% of patients in the high-risk score category had favorable disease). This translates to 39% of patients in this study population having risk scores ≤0.33 or >0.8, of which 81% were correctly identified by ProMark®. Of patients with intermediate risk scores (0.33< risk score ≤0.8), 58.3% had favorable disease. The PPV of ProMark® was also compared with those of the NCCN and D’Amico risk categories. The PPV for favorable pathology, at a risk score of ≤0.33, was 75% for patients in the NCCN intermediate-risk category; 81.5% for NCCN low-risk patients, and 95% for NCCN very low-risk, with an overall PPV for favorable pathology of 85%. This contrasts favorably with the PPVs obtained for the NCCN risk categories alone, which were 40.9% for intermediate risk, 63.8% for low-risk, and 80.3% for very low-risk.

These findings suggest that the ProMark® risk score provides additional confidence that a patient categorized to the NCCN very low-risk group indeed has a favorable pathology based on his biopsy from 80.3% to 95%. Conversely, the predictive value for non-favorable pathology was 76.9% at a risk score >0.8, but reached 100% at a risk score cutoff point of >0.9. For all NCCN and D'Amico risk categories, a higher ProMark® risk score correlated with decreased frequency of favorable cases.

Analysis of Evidence (Rationale for Determination)

Level of Evidence:
Quality – Limited to Moderate
Strength – Limited to Moderate
Weight - Limited

Criteria for Coverage
The ProMark® assay is covered only when the following clinical conditions are met:

  • Needle biopsy with localized adenocarcinoma of prostate (no clinical evidence of metastasis or lymph node involvement), and
  • Patient Stage as defined by one of the following:
    • Very Low Risk Disease (T1c AND Gleason Score ≤ 6 AND PSA ≤ 10 ng/mL AND <3 prostate cores with tumor AND  ≤ 50% cancer in any core AND PSA density of < 0.15 ng/mL/g) OR
    • Low Risk Disease (T1-T2a AND Gleason Score ≤ 6 AND PSA ≤ 10 ng/mL), and
  • Patient has an estimated life expectancy of greater than or equal to 10 years, and
  • Patient is a candidate for and is considering conservative therapy and yet and would be eligible for definitive therapy (radical prostectomy, radiation therapy or brachytherapy), and
  • Patient has not received pelvic radiation or androgen deprivation therapy prior to the biopsy, and
  • Test is ordered by a physician certified in the Metamark Genetics Certification and Training Registry (CTR), and
  • Patient is monitored for disease progression according to active surveillance guidelines as recorded in NCCN guidelines, and
  • Physician must report the development of metastasis or prostate cancer deaths in patients not treated definitively who were deemed low risk by the assay.

Certification and Training Registry (CTR) Program
Because of the complicated nature of management decisions utilizing the ProMark® assay and the potential for adverse harm to patients if the test is not used appropriately, testing must be furnished only by physicians who are enrolled in a Molecular Diagnostic Services Program (MolDX®) approved ProMark® CTR program. This serves to assure the appropriate selection of patients, compliance with management decisions and stringent follow up to ensure the benefits of the test outweigh its risks. As part of this requirement Metamark will provide to the Contractor reports every 6 months in a mutually agreed upon format.

The goals of the Metamark Genetics ProMark® CTR program are as follows:

  • To ensure that physicians understand the limitations of the test based on its validation, and
  • To inform prescribers and patients on the safe-use conditions for ProMark® assay, and
  • To make a good faith effort to identify any safety concerns from the use of the test, and
  • To facilitate understanding of the incremental clinical utility of the test versus adherence to current NCCN guidelines

This Contractor expects Metamark Genetics to:

  • Establish and maintain the ProMark® Certification and Training Registry (CTR);
  • Ensure that healthcare providers who order the ProMark® assay are registered and certified in the ProMark® CTR program and that the ProMark® assay is available only through these providers;
  • Maintain a secure registry database of Metamark's ProMark® CTR providers and obtain from referring physicians;
    • NCCN risk group and treatment recommendation based on current NCCN guidelines prior to receipt of test result;
    • Test result (i.e., ProMark® Risk Score), and
      • Treatment recommendation based on test results, and
      • Final physician-patient treatment decision, and
      • Report utilization data by clinic-pathologic staging;
      • Any subsequent change in patient treatment decision, even if the patient has not progressed, and
      • Immediately report (for patients not treated definitively who were deemed very low or low risk by the assay)
        • Progression as defined by current NCCN guidelines for patients on AS, or
        • Development of metastases, or
        • Prostate cancer deaths.
  • Share all required data and reports in a HIPAA complaint fashion.

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
Associated Information
Sources of Information
Open Meetings
Meeting Date Meeting States Meeting Information
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
MAC Meeting Information URLs
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

Revenue Codes

Code Description


Group 1

Group 1 Paragraph


Group 1 Codes



ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:


Group 1 Codes:



ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:


Group 1 Codes:



Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements
The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See “Coverage Indications, Limitations, and/or Medical Necessity") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available to the MAC upon request.

Sources of Information


  1. Blume-Jensen P, Berman DM, Rimm DL, et al. Development and clinical validation of an in situ biopsy-based multimarker assay for risk stratification in prostate cancer. Clin Cancer Res. 2015;21(11):2591-2600. doi:10.1158/1078-0432.CCR-14-2603
  2. D'Amico AV, Whittington R, Malkowicz SB, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA. 1998;280(11):969-974. doi:10.1001/jama.280.11.969
  3. National Cancer Institute. Cancer stat facts. Surveillance, Epidemiology, and End Results Program. http://seer.cancer.gov/statfacts/html/. Accessed November 17, 2023.
  4. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Prostate Cancer. Version 1.2022. https://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf. Accessed November 17, 2023.
  5. Resnick MJ, Koyama T, Fan KH, et al. Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med. 2013;368(5):436-445. doi:10.1056/NEJMoa1209978
  6. Shipitsin M, Small C, Giladi E, et al. Automated quantitative multiplex immunofluorescence in situ imaging identifies phospho-S6 and phospho-PRAS40 as predictive protein biomarkers for prostate cancer lethality. Proteome Sci. 2014;12:40. doi:10.1186/1477-5956-12-40
  7. Shipitsin M, Small C, Choudhury S, et al. Identification of proteomic biomarkers predicting prostate cancer aggressiveness and lethality despite biopsy-sampling error. Br J Cancer. 2014;111(6):1201-1212. doi:10.1038/bjc.2014.396
  8. Truong M, Slezak JA, Lin CP, et al. Development and multi-institutional validation of an upgrading risk tool for Gleason 6 prostate cancer. Cancer. 2013;119(22):3992-4002. doi:10.1002/cncr.28303
  9. Wilt TJ, Brawer MK, Jones KM, et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med. 2012;367(3):203-213. doi:10.1056/NEJMoa1113162

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
12/28/2023 R9

12/28/2023: Biannual review completed 11/20/2023 with no change in coverage. Minor grammatical changes made throughout. Updated accession dates for reference #3 and #4.

  • Other
02/24/2022 R8

Posted 02/24/2022-Added registered trademark symbol to ProMark® throughout the document. Under Bibliography changes were made to citations to reflect AMA citation. Review completed 01/13/2022.

  • Other
09/30/2021 R7

09/30/2021-Removed “MolDX:” from the title of this LCD.

  • Other
10/29/2020 R6

10/29/20 Review completed 09/15/2020 Bibliography updated to AMA format.

  • Other (Review)
11/01/2019 R5

Change Request (CR) 10901 Local Coverage Determinations (LCDs): it will no longer be appropriate to include Current Procedure Terminology (CPT)/Health Care Procedure Coding System (HCPCS) codes or International Classification of Diseases Tenth Revision-Clinical Modification (ICD-10-CM) codes in the LCDs. All CPT/HCPCS and ICD-10 codes have been removed from this LCD and placed in Billing and Coding: Immune Globulins
related to this LCD. Consistent with Change Request 10901, if any language from IOMs and/or regulations was present in the LCD, it has been removed and the applicable manual/regulation has been referenced.

  • Other (compliance with CR 10901)
11/01/2018 R4

11/01/2018-Annual review completed 10/11/2018.

  • Other (Annual Review)
05/01/2018 R3

05/01/2018-Removed CDD from title and added “OR” back into table before PSA scores for Intermediate and High-Risk Categories.

  • Other
12/01/2017 R2


12/01/2017-Added information under Analysis of evidence section & corrected typos. Annual Review completed 11/06/2017.


  • Other
11/01/2017 R1

11/01/2017: Added Gleason grade score to the low, intermediate and high risk table. Updated NCCN guideline in the source of information section. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other

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Public Versions
Updated On Effective Dates Status
12/20/2023 12/28/2023 - N/A Currently in Effect You are here
02/16/2022 02/24/2022 - 12/27/2023 Superseded View
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