June 27, 2022
Recently, SNMMI received word from our membership that Aetna's current cardiac PET policy refuses coverage for hybrid PET/CT (CPT codes 78429-78431, 78433) on the basis 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.” Specifically, the policy stated, "The fusion of PET and CT imaging into a single system (PET/CT fusion) is considered experimental and investigational for cardiac indications; a PET scan without CT is adequate to evaluate the myocardium (NIA, 2005)."
Together with the American Society of Nuclear Cardiology (ASNC), SNMMI sent a letter to Aetna requesting that their non-coverage policy be reversed, noting, "this decision is inconsistent with standards and practice for cardiac PET imaging across the United States." Not covering hybrid PET/CT denies patient access to standard-of-care testing that is required to make life-saving clinical decisions. SNMMI and ASNC’s recommendations regarding the role of PET/CT in the evaluation of coronary artery disease have been accepted by the American Medical Association (AMA) RVS Update Committee (RUC) and multiple payers, including CMS.
We are thrilled to communicate to our membership that within a few days of receiving our letter, Aetna reversed their non-coverage policy. SNMMI applauds this outcome and appreciates Aetna's swift response.
In 2016, ASNC imaging guidelines / SNMMI procedure standards were published that detail the quality components required to perform PET nuclear cardiology procedures. In addition, 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 and led to reimbursement by the Centers for Medicare and Medicaid Services and most other payers for those procedures with Category I codes.
Additionally, Aetna recently updated and published their coverage policy for PSMA imaging for PLUVICTO(TM) therapy eligibility. Aetna now covers hormone and chemo refractory mCRPC patients with PSMA avid disease imaged with any of the approved PSMA agents including PYLARIFY. Importantly the policy does not specify imaging with Ga-611. The highlights of the policy are:
Aetna considers lutetium Lu 177 vipivotide tetraxetan (Pluvicto) medically necessary for treatment (up to 6 total doses) of prostate cancer when all of the following criteria are met:
• The member has metastatic castration-resistant prostate cancer; and
• The member has been treated with androgen receptor (AR) pathway inhibition (e.g., abiraterone) and taxane-based chemotherapy (e.g., docetaxel); and
• The disease is prostate-specific membrane antigen (PSMA)-positive.
Aetna considers lutetium Lu 177 vipivotide tetraxetan (Pluvicto) experimental and investigational for all other indications. The full policy determination is available to view at: http://www.aetna.com/cpb/medical/data/900_999/0929.html
The SNMMI Health Policy Team works diligently to ensure that coverage policies are up-to-date with current literature. We encourage our membership to report non-coverage issues to us at firstname.lastname@example.org.