SNMMI Objects to Humana’s Decision to Deny Coverage for PET/CT

November 12, 2020

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 February 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; OR
  • Gastric or esophageal oncologic indications; OR
  • Neurologic indications; OR
  • Total body PET/CT (uEXPLORER) for screening (e.g. cancer).”

SNMMI has joined several other medical societies, including ASNC, in opposing this decision by Humana.  In 2016, ASNC imaging guidelines /SNMMI procedure standards [1] were published that detail the quality components required to perform PET nuclear cardiology procedures.  In 2020, a multi-disciplinary appropriate use criteria (AUC) document [2] 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).” [3-6]  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.

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.  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. With this policy, Humana is thus requiring its members to provide cardiac PET services using less advanced instrumentation than is currently available.  Hybrid PET/CT systems also 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.  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.

You may find SNMMI's letter to Humana regarding its refusal to cover hybrid PET/CT for cardiac indications here. We are also in the process of drafting another letter regarding the other exclusions.

 

[1] Dilsizian V, Bacharach SL, Beanlands SR, Bergmann SR, Delbeke D, Dorbala S, et al. ASNC Imaging Guidelines/SNMMI Procedure Standard for Positron Emission Tomography (PET) Nuclear Cardiology Procedures. J Nucl Cardiol 2016; 23:1187-1226.

[2] Schindler TH, Bateman TM, Berman DS, Chareonthaitawee P, De Blanche LE, Dilsizian V, Dorbala S, Gropler RJ, Shaw L, Soman P, Winchester DE, Verberne H, Ahuja S, Beanlands RS, Di Carli MF, Murthy VL, Ruddy TD, Schwartz RG. Appropriate Use Criteria for PET Myocardial Perfusion Imaging. J Nucl Med. 2020 Aug;61(8):1221-1265. doi: 10.2967/jnumed.120.246280. PMID: 32747510.

[3] Bateman TM, Dilsizian V, Beanlands RS, DePuey EG, Heller GV, Wolinsky DA. American Society of Nuclear Cardiology and Society of Nuclear Medicine and Molecular Imaging joint position statement on the clinical indications for myocardial perfusion PET. J Nucl Cardiol. 2016;23: 1227–1231.

[4] Schindler TH, Schelbert HR, Quercioli A, Dilsizian V. Cardiac PET imaging for the detection and monitoring of coronary artery disease and microvascular health. JACC Cardiovasc Imaging. 2010;3:623–640.

[5] Gould KL, Johnson NP, Bateman TM, et al. Anatomic versus physiologic assessment of coronary artery disease: role of coronary flow reserve, fractional flow reserve, and positron emission tomography imaging in revascularization decision-making. J Am Coll Cardiol. 2013;62:1639–1653.

[6] Gould KL, Johnson NP, Roby AE, et al. Regional, artery-specific thresholds of quantitative myocardial perfusion by PET associated with reduced myocardial infarction and death after revascularization in stable coronary artery disease. J Nucl Med. 2019;60:410–417.