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Update: Humana Reverses Non-Oncologic PET/CT Non-Coverage Policy
June 21, 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]. 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.
Months ago, Humana reversed its decision to deny coverage for PET/CT imaging of gastric and esophageal oncologic indications, and now we have more good news. Humana's medical review panel convened at the end of May to decide whether to cover PET/CT for cardiac/neurologic indications and SPECT/CT. The result was a generous cardiac PET/CT coverage policy that is current with the evidence and CMS's National Coverage decision on 18F FDG PET for infection and inflammation. The policy is currently in draft form but details the following:
- Myocardial viability assessment as indicated by one or more of the following:
- Chronic secondary mitral regurgitation, and individual is candidate for revascularization if viable myocardium identified
- Known or suspected ischemic cardiomyopathy with left ventricular ejection fraction 35% or less
- SPECT myocardial perfusion scan or stress echocardiogram findings inconclusive, or no viable myocardium evident; OR
- Suspected prosthetic valve endocarditis as indicated by ALL of the following:
- Clinical suspicion of endocarditis; AND
- Non-diagnostic echocardiogram results; AND
- Prosthetic valve implanted more that three months prior; OR
- Sarcoidosis with suspected cardiac involvement.
Humana's draft policy also made some changes to SPECT/CT and PET/CT for neurologic indications:
- Humana members may be eligible under the plan for SPECT with concurrently acquired CT for preoperative localization of parathyroid adenomas.
- Humana members may be eligible under the plan for PET with concurrently acquired CT for pre-surgical evaluation to localize the focus of refractory seizure activity.
In particular, "SNMMI has been advocating for [coverage of] this indication [suspected prosthetic valve endocarditis] for the past five years, writing numerous articles and editorials, including it in our PET procedure guidelines, and more recently submitting a consensus document to JACC: Cardiovascular Imaging for FDG PET/CT in prosthetic valve endocarditis and cardiac device-related infections," remarked Vasken Dilsizian, MD, FSNMMI. We are grateful Humana took our concerns seriously and look forward to working together to expand SPECT/CT coverage.