A Partial Win: Humana Reverses PET/CT Non-Coverage Policy

April 27, 2021

Since November 2020, SNMMI has been in communications with Humana regarding their decision to deny coverage for PET/CT and SPECT/CT on the basis that they are “experimental/investigational” and “not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature.” [Humana Policy Number: HCS-0506-010; PET/CT CPT® codes 78429-78433; SPECT/CT codes 78830, 78832]

The latest update to Humana's policy, which added CPT code 78433 to the list of non-covered codes, took effect February 4, 2021, and 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; OR
  • Gastric or esophageal oncologic indications; OR
  • Neurologic indications; OR
  • Total body PET/CT (uEXPLORER) for screening (e.g. cancer)…

There is ample evidence in the peer-reviewed literature—as well as in clinical guidelines and appropriate use criteria—supporting the use of PET/CT and SPECT/CT. This evidence is widely accepted by payers, including the Centers for Medicare and Medicaid Services and the American Medical Association. Implementation of Humana's revised policy would deny patients access to state-of-the-art imaging procedures that are the standard of care for supporting potentially life-saving clinical decisions.

After writing two letters to Humana, SNMMI leadership and key members met with the commercial payer on January 21, 2021, to discuss its policy decision to exclude hybrid PET/CT for certain indications and SPECT/CT from coverage. Thankfully, Humana reversed its decision to deny coverage for PET/CT imaging of gastric and esophageal oncologic indications. Humana's medical review panel will convene again in May to decide whether to cover PET/CT for cardiac/neurologic indications and SPECT/CT. SNMMI will continue to monitor this issue and will inform the membership once a decision is reached.

SNMMI's letter to Humana regarding coverage of hybrid PET/CT for cardiac indications is here, and a separate letter pertaining to other exclusions is here. A letter signed by patient groups opposing Humana's decision, coordinated by SNMMI, is here.