December 10, 2020

ACR Asks Humana to Reconsider PET CT Non-Coverage Policy

In a Dec. 4 letter, the American College of Radiology® (ACR®) expressed concern about a recent policy decision by Humana to deny coverage of certain PET/CT exams on the basis that it is “experimental/investigational” and “not identified as widely used …” Specific indications listed for non-coverage include, but are not limited to, cardiac indications, gastric or esophageal oncologic indications, neurologic indications, and total body PET/CT for screening. The policy is scheduled to take effect on Feb. 4, 2021.

The ACR commented that this decision by Humana denies patient access to standard-of-care testing that is required to make lifesaving clinical decisions. The Society of Nuclear Medicine and Molecular Imaging and the American Society of Nuclear Cardiology’s recommendations regarding the role of PET/CT in the evaluation of coronary artery disease have been accepted by multiple payers, including the Centers for Medicare and Medicaid Services.

Nearly all currently available PET scanners are now hybrid PET/CT systems, and these newer systems include numerous improvements compared to older, non-hybrid, systems. With this policy, Humana is thus requiring its members to obtain cardiac PET services on less advanced equipment. Integrated PET/CT systems reduce scan time, which also reduces patient motion, leading to higher quality images. The CT attenuation correction can also be customized for body habitus, again contributing to a higher quality image. For cardiac PET/CT, there is also extensive medical literature documenting the additional diagnostic value contributed by review of the CT attenuation map image for coronary calcium.

Questions on this policy and on ACR comments should be directed to Katie Keysor, ACR Senior Director of Economic Policy.