On November 6, SNMMI received word regarding Humana’s recent decision [Policy Number: HCS-0506-010] to deny coverage for PET/CT (CPT codes 78429-78433) on the basis that it is “experimental/investigational” and “not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature.”
The revised policy, to take effect Feb. 4, 2021, reads: “Humana members may NOT be eligible under the Plan for PET with concurrently acquired CT for any indications other than those listed above, including, but not limited to:
- Cardiac indications
- Gastric or esophageal oncologic indications
- Neurologic indications
- Total body PET/CT (uEXPLORER) for screening (e.g., cancer).”
SNMMI has joined several other medical societies, including the American Society of Nuclear Cardiology (ASNC), in opposing this decision by Humana. In 2016, ASNC imaging guidelines/SNMMI procedure standards were published that detail the quality components required to perform PET nuclear cardiology procedures.
In 2020, a multi-disciplinary appropriate use criteria (AUC) document published by SNMMI states: “The high spatial and contrast resolution in concert with photon attenuation-free images of PET have led to high image quality associated with the highest sensitivity and specificity of PET/CT perfusion imaging in the detection and characterization of coronary artery disease (CAD).” The publication of these peer-reviewed documents validated the role of cardiac PET/CT and led to reimbursement by the Centers for Medicare and Medicaid Services, and most other payers, for these procedures with Category I codes, SNMMI officials say.
“With respect to other indications, PET/CT with FDG has an established role in evaluating esophageal cancers and cancers of the gastroesophageal junction, and this has been affirmed by national CMS coverage policies,” SNMMI officials add. “In addition, several neurologic indications are appropriate for PET/CT. While screening low-risk patients for cancer by PET is not routine practice, the appropriateness of evaluating high-risk patients for cancer will be defined by the clinical context and clinical question.
“Nearly all commercially available PET scanners are now hybrid PET/CT systems, and these newer systems have numerous other improvements compared to older models,” SNMMI officials continue. “Hybrid PET/CT systems reduce scan time and patient motion, leading to higher quality images. CT attenuation corrections can also be customized for body habitus, further improving image quality. For cardiac PET, there is also extensive medical literature documenting the additional diagnostic value contributed by review of the CT attenuation map image.”
In summary, SNMMI strongly disagrees with Humana’s recently proposed policy decision to exclude hybrid PET/CT imaging for cardiac and several other indications as “experimental” and “investigational.” “There is ample evidence in the peer-reviewed literature as well as clinical guidelines and appropriate use criteria that support the use of PET/CT,” SNMMI officials say. “This evidence is widely accepted by payers, including CMS, and by the AMA. Implementing this revised policy will deny patients access to state-of-the-art imaging procedures that are the standard-of-care for making potentially life-saving clinical decisions.”