Aetna · Clinical coverage policy

Aetna Positron Emission Tomography (PET) coverage criteria

Aetna CPB 0071 covers PET and PET/CT as medically necessary for defined cardiac uses (Rb-82/N-13 ammonia perfusion in place of SPECT or post-transplant, FDG myocardial viability, AQMBF adjunct, cardiac sarcoidosis), a long list of specified cancers for diagnosis/staging/restaging (judged against eviCore guidelines, with specialty radiotracers for prostate, neuroendocrine, breast, meningioma, and medullary thyroid), epilepsy pre-surgical seizure localization, amyloid PET only when an Alzheimer anti-amyloid drug is being considered, and several rare histiocytic/vasculitic conditions. The key gate is that PET must change clinical management and either resolve diagnostic doubt remaining after conventional imaging or replace conventional studies; post-treatment surveillance (no signs/symptoms), PET/MRI, screening, and many specific tumor types and tracer uses are experimental/investigational and not covered.

Policy CPB 0071 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0071

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0071 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Positron Emission Tomography (PET) (CPT 78811), and what gets it denied?

Path
Aetna CPB 0071 covers PET and PET/CT as medically necessary for defined cardiac uses (Rb-82/N-13 ammonia perfusion in place of SPECT or post-transplant, FDG myocardial viability, AQMBF adjunct, cardiac sarcoidosis), a long list of specified cancers for diagnosis/staging/restaging (judged against eviCore guidelines, with specialty radiotracers for prostate, neuroendocrine, breast, meningioma, and medullary thyroid), epilepsy pre-surgical seizure localization, amyloid PET only when an Alzheimer anti-amyloid drug is being considered, and several rare histiocytic/vasculitic conditions. The key gate is that PET must change clinical management and either resolve diagnostic doubt remaining after conventional imaging or replace conventional studies; post-treatment surveillance (no signs/symptoms), PET/MRI, screening, and many specific tumor types and tracer uses are experimental/investigational and not covered. Coverage criteria include: CARDIAC - Rb-82 or N-13 ammonia PET (rest or pharmacological stress) for non-invasive imaging of heart perfusion for diagnosis/management of known or suspected coronary artery disease, medically necessary if EITHER ONE of: (1) PET used IN PLACE OF (not in addition to) SPECT in persons who meet medical necessity criteria for cardiac SPECT; OR (2) for assessment of CAD after cardiac transplant; CARDIAC - FDG-PET for determination of myocardial viability prior to revascularization, either as a primary/initial diagnostic study OR following an inconclusive SPECT (a SPECT following an inconclusive PET is NOT medically necessary due to greater specificity of PET); CARDIAC - Absolute quantitation of myocardial blood flow (AQMBF) as a medically necessary adjunct to cardiac PET WHEN criteria for rest/stress perfusion for coronary artery disease are met; CARDIAC - FDG-PET to identify and monitor response to therapy for established or strongly suspected cardiac sarcoid (cardiac sarcoidosis); ONCOLOGY general - DIAGNOSIS: FDG-PET medically necessary where PET results may assist in avoiding an invasive diagnostic procedure OR in determining the optimal anatomic location to perform an invasive diagnostic procedure (for most solid tumors a tissue diagnosis is generally made prior to PET); ONCOLOGY general - STAGING: medically necessary in situations where clinical management would differ depending on the stage AND EITHER (1) stage remains in doubt after completion of a standard diagnostic work-up including conventional imaging (CT, MRI, or ultrasound); OR (2) PET would potentially replace one or more conventional imaging studies when conventional study information is expected to be insufficient for clinical management; ONCOLOGY general - RESTAGING: medically necessary after completion of treatment to detect residual disease, to detect suspected recurrence in persons WITH signs or symptoms of recurrence, or to determine extent of recurrence; ALSO medically necessary if it could potentially replace one or more conventional imaging studies when conventional study information is expected to be insufficient for clinical management; ONCOLOGY - FDG-PET medically necessary for the following cancers per eviCore oncology imaging guidelines when medical necessity criteria met (initial staging/restaging/recurrence as applicable): adrenal carcinoma, adrenocortical tumors, ampullary, anal, appendiceal, brain, breast, Burkitt's lymphoma, Castleman's disease, cervical, chordoma, CLL/SLL with Richter's transformation, colorectal, DLBCL, esophageal, Ewing sarcoma, osteosarcoma, fallopian tube, follicular lymphoma, gallbladder, gastric, gastrointestinal stromal tumor, head/neck, Hodgkin lymphoma, light-chain deposition disease, mantle cell lymphoma, marginal zone/MALT lymphoma, melanoma, Merkel cell, mesothelioma, multiple myeloma, plasmacytomas, neuroblastoma, neuroendocrine tumors, NHL, NSCLC, SCLC, occult primary, ovarian, pancreatic, paraneoplastic syndrome, penile, post-transplant lymphoproliferative disorder, primary cutaneous B-cell lymphoma, primary peritoneal, skin, small bowel adenocarcinoma, soft tissue sarcoma, solitary pulmonary nodules, T-cell lymphoma variants, testicular, thymic, thyroid, urothelial carcinoma, uterine sarcoma, vaginal, vulvar squamous cell; ONCOLOGY catch-all - Upon INDIVIDUAL CASE REVIEW, FDG-PET may be considered medically necessary for OTHER oncologic indications not specifically listed, WHEN the conventional imaging indicated for that indication is EQUIVOCAL AND the general medical necessity criteria for oncologic indications are met; PROSTATE - Fluciclovine F-18 PET OR Choline C-11 PET medically necessary for RESTAGING of men with a SUSPECTED RECURRENCE of prostate cancer when eviCore oncology imaging guideline medical necessity criteria met; PROSTATE - Ga-68 PSMA-11 AND Piflufolastat F-18 (Pylarify) medically necessary for NEWLY DIAGNOSED and SUSPECTED RECURRENCE of prostate cancer when eviCore oncology imaging guideline medical necessity criteria met; PROSTATE - 18F-flotufolastat (Posluma) injection medically necessary for PET imaging of PSMA-positive lesions in individuals with prostate cancer when eviCore oncology imaging guideline medical necessity criteria met; PROSTATE - Kit for preparation of gallium Ga 68 gozetotide (Gozellix, Illuccix, Locametz) PET of PSMA-positive lesions medically necessary in men with prostate cancer when eviCore oncology imaging guideline medical necessity criteria met; NEUROENDOCRINE - Gallium Ga 68 dotatate (Netspot), Gallium Ga 68 DOTA-TOC, and Copper Cu 64 dotatate PET medically necessary for LOW-GRADE neuroendocrine tumors when eviCore oncology imaging guideline medical necessity criteria met; MENINGIOMA - Ga 68 dotatate OR Ga 68 DOTA-TOC PET medically necessary for meningioma, for SUSPECTED RECURRENCE with INCONCLUSIVE findings on MRI, when eviCore oncology imaging guideline medical necessity criteria met; MEDULLARY THYROID CANCER - Ga 68 dotatate OR Ga 68 DOTA-TOC PET medically necessary for RESTAGING medullary thyroid cancer, for INCONCLUSIVE findings on conventional imaging, when eviCore oncology imaging guideline medical necessity criteria met; BREAST - Cerianna (fluoroestradiol F-18) PET medically necessary for detection of estrogen receptor (ER)-positive lesions as an ADJUNCT TO BIOPSY in RECURRENT or METASTATIC breast cancer when eviCore oncology imaging guideline medical necessity criteria met; NEUROLOGY (Alzheimer/cognitive) - Amyloid PET scan (florbetapir F18 [Amyvid], florbetaben F18 [Neuraceq], flortaucipir F18 [Tauvid], flutemetamol F18 [Vizamyl]) medically necessary for persons with mild cognitive impairment due to Alzheimer disease who are being considered for aducanumab (Aduhelm), lecanemab-irmb (Leqembi), OR donanemab-azbt (Kisunla) therapy; NEUROLOGY (epilepsy) - FDG-PET medically necessary ONLY for pre-surgical evaluation for the purpose of localization of a focus of refractory seizure activity; PET/CT FUSION - considered medically necessary for ANY indication where PET scanning is considered medically necessary; OTHER non-oncologic - FDG-PET for diagnosis, staging, and restaging of Langerhans cell histiocytosis; OTHER non-oncologic - FDG-PET for evaluation of large-vessel vasculitis (including giant cell arteritis and Takayasu arteritis) WHEN diagnosis is uncertain FOLLOWING NEGATIVE temporal artery biopsy results; OTHER non-oncologic - FDG-PET for staging and restaging of Erdheim-Chester disease; OTHER non-oncologic - FDG-PET for staging and restaging of hemangiopericytoma; OTHER non-oncologic - FDG-PET for staging, restaging, and surveillance of Rosai-Dorfman disease; OTHER non-oncologic - FDG-PET for workup of monoclonal gammopathy of undetermined significance (MGUS) IF CT/MRI are negative. Applies to 13 codes: 78811, 78812, 78813, 78814, 78815, 78816, 78429, 78430, 78431, 78432, 78459, 78491, 78492.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Precertification may be required for select procedures and interventions. Use the CPT code search tool to see if precertification is required. Many oncologic indications are adjudicated against eviCore oncology imaging guidelines.
Trap
Policy exclusions and limitations: ONCOLOGY SURVEILLANCE - PET for post-treatment surveillance is experimental, investigational, or unproven (surveillance = use of PET beyond completion of treatment, in the ABSENCE of signs or symptoms of cancer recurrence or progression, for the purpose of detecting recurrence/progression or predicting outcome); AMYLOID PET - experimental/investigational for sporadic cerebral amyloid angiopathy; AMYLOID PET - florbetapir-PET experimental/investigational for cerebral amyloid angiopathy-related hemorrhages; Carbon-11 labeled 5-HTP PET - experimental/investigational for carcinoid and all other indications; FDG-PET non-oncologic - experimental/investigational for adrenoleukodystrophy; FDG-PET non-oncologic - experimental/investigational for chronic osteomyelitis; FDG-PET non-oncologic - experimental/investigational for coccidioidomycosis; FDG-PET non-oncologic - experimental/investigational for cortico-basal syndrome; FDG-PET non-oncologic - experimental/investigational for eosinophilia; FDG-PET non-oncologic - experimental/investigational for fever of unknown origin; FDG-PET non-oncologic - experimental/investigational for hepatic encephalopathy; FDG-PET non-oncologic - experimental/investigational for knee replacement prostheses infection; FDG-PET non-oncologic - experimental/investigational for hip arthroplasty infection; FDG-PET non-oncologic - experimental/investigational for joint infection; FDG-PET non-oncologic - experimental/investigational for osteoarthritis joint inflammation; FDG-PET non-oncologic - experimental/investigational for lymphangiomatosis; FDG-PET non-oncologic - experimental/investigational for mesenteric lymphadenopathy; FDG-PET non-oncologic - experimental/investigational for Moyamoya disease; FDG-PET non-oncologic - experimental/investigational for Parkinson disease neurodegenerative progression; FDG-PET non-oncologic - experimental/investigational for opsoclonus myoclonus syndrome; FDG-PET non-oncologic - experimental/investigational for pigmented villonodular synovitis; FDG-PET non-oncologic - experimental/investigational for pleural effusion; FDG-PET non-oncologic - experimental/investigational for rheumatoid arthritis; FDG-PET non-oncologic - experimental/investigational for sarcoidosis (EXCEPT cardiac sarcoidosis, which is medically necessary); FDG-PET non-oncologic - experimental/investigational for Li-Fraumeni screening; FDG-PET non-oncologic - experimental/investigational for splenomegaly; FDG-PET non-oncologic - experimental/investigational for Takayasu's arteritis (as a standalone non-oncologic indication outside the covered large-vessel vasculitis post-negative-biopsy criterion); FDG-PET non-oncologic - experimental/investigational for xanthogranuloma; FDG-PET non-oncologic - experimental/investigational for all other unlisted non-oncologic indications; FDG-PET oncologic - experimental/investigational for amyloidosis follow-up in transplant recipients; FDG-PET oncologic - experimental/investigational for atypical teratoid/rhabdoid tumor; FDG-PET oncologic - experimental/investigational for chondrosarcoma; FDG-PET oncologic - experimental/investigational for clear cell carcinoma of the uterus; FDG-PET oncologic - experimental/investigational for desmoid tumors; FDG-PET oncologic - experimental/investigational for endometrial cancer; FDG-PET oncologic - experimental/investigational for intraductal papillary mucinous neoplasm of the pancreas; FDG-PET oncologic - experimental/investigational for gestational trophoblastic neoplasia; FDG-PET oncologic - experimental/investigational for giant cell tumor of bone; FDG-PET oncologic - experimental/investigational for hemangioendothelioma; FDG-PET oncologic - experimental/investigational for hepatic sarcoma; FDG-PET oncologic - experimental/investigational for hepatocellular carcinoma; FDG-PET oncologic - experimental/investigational for hypercalcemia of malignancy; FDG-PET oncologic - experimental/investigational for kidney cancer; FDG-PET oncologic - experimental/investigational for leukemia; FDG-PET oncologic - experimental/investigational for malignant neurofibromas; FDG-PET oncologic - experimental/investigational for neurofibromatosis; FDG-PET oncologic - experimental/investigational for neuroganglioma of the psoas; FDG-PET oncologic - experimental/investigational for osteoblastoma; FDG-PET oncologic - experimental/investigational for Paget's disease; FDG-PET oncologic - experimental/investigational for peri-ampullary cancer; FDG-PET oncologic - experimental/investigational for pilar tumor; FDG-PET oncologic - experimental/investigational for pituitary adenoma; FDG-PET oncologic - experimental/investigational for placental cancer; FDG-PET oncologic - experimental/investigational for plasmacytoid dendritic cell neoplasm; FDG-PET oncologic - experimental/investigational for pleomorphic adenoma; FDG-PET oncologic - experimental/investigational for schwannoma; FDG-PET oncologic - experimental/investigational for salivary gland tumors; FDG-PET oncologic - experimental/investigational for serous papillary endometrial carcinoma; FDG-PET oncologic - experimental/investigational for solitary fibrous tumors; FDG-PET oncologic - experimental/investigational for spindle cell sarcoma; FDG-PET oncologic - experimental/investigational for surgical planning of PEComas; FDG-PET oncologic - experimental/investigational for sweat gland tumor; FDG-PET oncologic - experimental/investigational for uterine papillary mesothelioma; FDG-PET oncologic - experimental/investigational for Waldenstrom macroglobulinemia restaging; FDG-PET oncologic - experimental/investigational for Wilms tumor; FDG-PET oncologic - experimental/investigational for all other unlisted oncologic indications; 11C-choline PET - experimental/investigational for hyperparathyroidism; 11C-metomidate PET - experimental/investigational for monitoring primary aldosteronism treatment response; 18F-FDOPA-PET - experimental/investigational for brain cancer prognosis; Fluorodopa F-18 PET - experimental/investigational for Parkinsonian syndromes / Parkinson disease; Ga-68 dotatate - experimental/investigational for SDHB mutation monitoring; NaF-18 (sodium fluoride F-18) PET - experimental/investigational for bone metastasis and other indications; PET - experimental/investigational for disseminated histoplasmosis imaging; PET - experimental/investigational for hepatoblastoma imaging; PET - experimental/investigational for SIRT (selective internal radiation therapy) planning, or for evaluation of abnormal CT after dermatofibrosarcoma resection; PET-probe guided surgical resection - experimental/investigational for recurrent ovarian cancer; PET - experimental/investigational for Huntington disease; PET - experimental/investigational for asymptomatic screening for breast, lung, or other cancers; PET/CT - experimental/investigational for monitoring littoral cell splenic angioma; PET/MRI - experimental/investigational for ALL indications (exceptions to cover PET/MRI may be made where PET/CT is unavailable and medical necessity criteria for FDG-PET are met); Gamma camera PET scanning - experimental/investigational; Positron emission mammography - experimental/investigational; SCINTIX biology-guided radiotherapy - experimental/investigational; PET - experimental/investigational for evaluation of unspecified periodic fever syndrome; FDG-PET as an alternative to 99mTc skeletal scintigraphy (bone scan) - NO LONGER acceptable: there is no longer a temporary shortage of technetium 99-m, therefore Aetna will no longer consider FDG-PET an acceptable alternative to bone scans. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0071 — Positron Emission Tomography (PET)

Coverage criteria

  • CARDIAC - Rb-82 or N-13 ammonia PET (rest or pharmacological stress) for non-invasive imaging of heart perfusion for diagnosis/management of known or suspected coronary artery disease, medically necessary if EITHER ONE of: (1) PET used IN PLACE OF (not in addition to) SPECT in persons who meet medical necessity criteria for cardiac SPECT; OR (2) for assessment of CAD after cardiac transplant
  • CARDIAC - FDG-PET for determination of myocardial viability prior to revascularization, either as a primary/initial diagnostic study OR following an inconclusive SPECT (a SPECT following an inconclusive PET is NOT medically necessary due to greater specificity of PET)
  • CARDIAC - Absolute quantitation of myocardial blood flow (AQMBF) as a medically necessary adjunct to cardiac PET WHEN criteria for rest/stress perfusion for coronary artery disease are met
  • CARDIAC - FDG-PET to identify and monitor response to therapy for established or strongly suspected cardiac sarcoid (cardiac sarcoidosis)
  • ONCOLOGY general - DIAGNOSIS: FDG-PET medically necessary where PET results may assist in avoiding an invasive diagnostic procedure OR in determining the optimal anatomic location to perform an invasive diagnostic procedure (for most solid tumors a tissue diagnosis is generally made prior to PET)
  • ONCOLOGY general - STAGING: medically necessary in situations where clinical management would differ depending on the stage AND EITHER (1) stage remains in doubt after completion of a standard diagnostic work-up including conventional imaging (CT, MRI, or ultrasound); OR (2) PET would potentially replace one or more conventional imaging studies when conventional study information is expected to be insufficient for clinical management
  • ONCOLOGY general - RESTAGING: medically necessary after completion of treatment to detect residual disease, to detect suspected recurrence in persons WITH signs or symptoms of recurrence, or to determine extent of recurrence; ALSO medically necessary if it could potentially replace one or more conventional imaging studies when conventional study information is expected to be insufficient for clinical management
  • ONCOLOGY - FDG-PET medically necessary for the following cancers per eviCore oncology imaging guidelines when medical necessity criteria met (initial staging/restaging/recurrence as applicable): adrenal carcinoma, adrenocortical tumors, ampullary, anal, appendiceal, brain, breast, Burkitt's lymphoma, Castleman's disease, cervical, chordoma, CLL/SLL with Richter's transformation, colorectal, DLBCL, esophageal, Ewing sarcoma, osteosarcoma, fallopian tube, follicular lymphoma, gallbladder, gastric, gastrointestinal stromal tumor, head/neck, Hodgkin lymphoma, light-chain deposition disease, mantle cell lymphoma, marginal zone/MALT lymphoma, melanoma, Merkel cell, mesothelioma, multiple myeloma, plasmacytomas, neuroblastoma, neuroendocrine tumors, NHL, NSCLC, SCLC, occult primary, ovarian, pancreatic, paraneoplastic syndrome, penile, post-transplant lymphoproliferative disorder, primary cutaneous B-cell lymphoma, primary peritoneal, skin, small bowel adenocarcinoma, soft tissue sarcoma, solitary pulmonary nodules, T-cell lymphoma variants, testicular, thymic, thyroid, urothelial carcinoma, uterine sarcoma, vaginal, vulvar squamous cell
  • ONCOLOGY catch-all - Upon INDIVIDUAL CASE REVIEW, FDG-PET may be considered medically necessary for OTHER oncologic indications not specifically listed, WHEN the conventional imaging indicated for that indication is EQUIVOCAL AND the general medical necessity criteria for oncologic indications are met
  • PROSTATE - Fluciclovine F-18 PET OR Choline C-11 PET medically necessary for RESTAGING of men with a SUSPECTED RECURRENCE of prostate cancer when eviCore oncology imaging guideline medical necessity criteria met
  • PROSTATE - Ga-68 PSMA-11 AND Piflufolastat F-18 (Pylarify) medically necessary for NEWLY DIAGNOSED and SUSPECTED RECURRENCE of prostate cancer when eviCore oncology imaging guideline medical necessity criteria met
  • PROSTATE - 18F-flotufolastat (Posluma) injection medically necessary for PET imaging of PSMA-positive lesions in individuals with prostate cancer when eviCore oncology imaging guideline medical necessity criteria met
  • PROSTATE - Kit for preparation of gallium Ga 68 gozetotide (Gozellix, Illuccix, Locametz) PET of PSMA-positive lesions medically necessary in men with prostate cancer when eviCore oncology imaging guideline medical necessity criteria met
  • NEUROENDOCRINE - Gallium Ga 68 dotatate (Netspot), Gallium Ga 68 DOTA-TOC, and Copper Cu 64 dotatate PET medically necessary for LOW-GRADE neuroendocrine tumors when eviCore oncology imaging guideline medical necessity criteria met
  • MENINGIOMA - Ga 68 dotatate OR Ga 68 DOTA-TOC PET medically necessary for meningioma, for SUSPECTED RECURRENCE with INCONCLUSIVE findings on MRI, when eviCore oncology imaging guideline medical necessity criteria met
  • MEDULLARY THYROID CANCER - Ga 68 dotatate OR Ga 68 DOTA-TOC PET medically necessary for RESTAGING medullary thyroid cancer, for INCONCLUSIVE findings on conventional imaging, when eviCore oncology imaging guideline medical necessity criteria met
  • BREAST - Cerianna (fluoroestradiol F-18) PET medically necessary for detection of estrogen receptor (ER)-positive lesions as an ADJUNCT TO BIOPSY in RECURRENT or METASTATIC breast cancer when eviCore oncology imaging guideline medical necessity criteria met
  • NEUROLOGY (Alzheimer/cognitive) - Amyloid PET scan (florbetapir F18 [Amyvid], florbetaben F18 [Neuraceq], flortaucipir F18 [Tauvid], flutemetamol F18 [Vizamyl]) medically necessary for persons with mild cognitive impairment due to Alzheimer disease who are being considered for aducanumab (Aduhelm), lecanemab-irmb (Leqembi), OR donanemab-azbt (Kisunla) therapy
  • NEUROLOGY (epilepsy) - FDG-PET medically necessary ONLY for pre-surgical evaluation for the purpose of localization of a focus of refractory seizure activity
  • PET/CT FUSION - considered medically necessary for ANY indication where PET scanning is considered medically necessary
  • OTHER non-oncologic - FDG-PET for diagnosis, staging, and restaging of Langerhans cell histiocytosis
  • OTHER non-oncologic - FDG-PET for evaluation of large-vessel vasculitis (including giant cell arteritis and Takayasu arteritis) WHEN diagnosis is uncertain FOLLOWING NEGATIVE temporal artery biopsy results
  • OTHER non-oncologic - FDG-PET for staging and restaging of Erdheim-Chester disease
  • OTHER non-oncologic - FDG-PET for staging and restaging of hemangiopericytoma
  • OTHER non-oncologic - FDG-PET for staging, restaging, and surveillance of Rosai-Dorfman disease
  • OTHER non-oncologic - FDG-PET for workup of monoclonal gammopathy of undetermined significance (MGUS) IF CT/MRI are negative

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Frequently asked questions

When does Aetna cover Positron Emission Tomography (PET) (CPT 78811), and what gets it denied?
Aetna CPB 0071 covers PET and PET/CT as medically necessary for defined cardiac uses (Rb-82/N-13 ammonia perfusion in place of SPECT or post-transplant, FDG myocardial viability, AQMBF adjunct, cardiac sarcoidosis), a long list of specified cancers for diagnosis/staging/restaging (judged against eviCore guidelines, with specialty radiotracers for prostate, neuroendocrine, breast, meningioma, and medullary thyroid), epilepsy pre-surgical seizure localization, amyloid PET only when an Alzheimer anti-amyloid drug is being considered, and several rare histiocytic/vasculitic conditions. The key gate is that PET must change clinical management and either resolve diagnostic doubt remaining after conventional imaging or replace conventional studies; post-treatment surveillance (no signs/symptoms), PET/MRI, screening, and many specific tumor types and tracer uses are experimental/investigational and not covered. Coverage criteria include: CARDIAC - Rb-82 or N-13 ammonia PET (rest or pharmacological stress) for non-invasive imaging of heart perfusion for diagnosis/management of known or suspected coronary artery disease, medically necessary if EITHER ONE of: (1) PET used IN PLACE OF (not in addition to) SPECT in persons who meet medical necessity criteria for cardiac SPECT; OR (2) for assessment of CAD after cardiac transplant; CARDIAC - FDG-PET for determination of myocardial viability prior to revascularization, either as a primary/initial diagnostic study OR following an inconclusive SPECT (a SPECT following an inconclusive PET is NOT medically necessary due to greater specificity of PET); CARDIAC - Absolute quantitation of myocardial blood flow (AQMBF) as a medically necessary adjunct to cardiac PET WHEN criteria for rest/stress perfusion for coronary artery disease are met; CARDIAC - FDG-PET to identify and monitor response to therapy for established or strongly suspected cardiac sarcoid (cardiac sarcoidosis); ONCOLOGY general - DIAGNOSIS: FDG-PET medically necessary where PET results may assist in avoiding an invasive diagnostic procedure OR in determining the optimal anatomic location to perform an invasive diagnostic procedure (for most solid tumors a tissue diagnosis is generally made prior to PET); ONCOLOGY general - STAGING: medically necessary in situations where clinical management would differ depending on the stage AND EITHER (1) stage remains in doubt after completion of a standard diagnostic work-up including conventional imaging (CT, MRI, or ultrasound); OR (2) PET would potentially replace one or more conventional imaging studies when conventional study information is expected to be insufficient for clinical management; ONCOLOGY general - RESTAGING: medically necessary after completion of treatment to detect residual disease, to detect suspected recurrence in persons WITH signs or symptoms of recurrence, or to determine extent of recurrence; ALSO medically necessary if it could potentially replace one or more conventional imaging studies when conventional study information is expected to be insufficient for clinical management; ONCOLOGY - FDG-PET medically necessary for the following cancers per eviCore oncology imaging guidelines when medical necessity criteria met (initial staging/restaging/recurrence as applicable): adrenal carcinoma, adrenocortical tumors, ampullary, anal, appendiceal, brain, breast, Burkitt's lymphoma, Castleman's disease, cervical, chordoma, CLL/SLL with Richter's transformation, colorectal, DLBCL, esophageal, Ewing sarcoma, osteosarcoma, fallopian tube, follicular lymphoma, gallbladder, gastric, gastrointestinal stromal tumor, head/neck, Hodgkin lymphoma, light-chain deposition disease, mantle cell lymphoma, marginal zone/MALT lymphoma, melanoma, Merkel cell, mesothelioma, multiple myeloma, plasmacytomas, neuroblastoma, neuroendocrine tumors, NHL, NSCLC, SCLC, occult primary, ovarian, pancreatic, paraneoplastic syndrome, penile, post-transplant lymphoproliferative disorder, primary cutaneous B-cell lymphoma, primary peritoneal, skin, small bowel adenocarcinoma, soft tissue sarcoma, solitary pulmonary nodules, T-cell lymphoma variants, testicular, thymic, thyroid, urothelial carcinoma, uterine sarcoma, vaginal, vulvar squamous cell; ONCOLOGY catch-all - Upon INDIVIDUAL CASE REVIEW, FDG-PET may be considered medically necessary for OTHER oncologic indications not specifically listed, WHEN the conventional imaging indicated for that indication is EQUIVOCAL AND the general medical necessity criteria for oncologic indications are met; PROSTATE - Fluciclovine F-18 PET OR Choline C-11 PET medically necessary for RESTAGING of men with a SUSPECTED RECURRENCE of prostate cancer when eviCore oncology imaging guideline medical necessity criteria met; PROSTATE - Ga-68 PSMA-11 AND Piflufolastat F-18 (Pylarify) medically necessary for NEWLY DIAGNOSED and SUSPECTED RECURRENCE of prostate cancer when eviCore oncology imaging guideline medical necessity criteria met; PROSTATE - 18F-flotufolastat (Posluma) injection medically necessary for PET imaging of PSMA-positive lesions in individuals with prostate cancer when eviCore oncology imaging guideline medical necessity criteria met; PROSTATE - Kit for preparation of gallium Ga 68 gozetotide (Gozellix, Illuccix, Locametz) PET of PSMA-positive lesions medically necessary in men with prostate cancer when eviCore oncology imaging guideline medical necessity criteria met; NEUROENDOCRINE - Gallium Ga 68 dotatate (Netspot), Gallium Ga 68 DOTA-TOC, and Copper Cu 64 dotatate PET medically necessary for LOW-GRADE neuroendocrine tumors when eviCore oncology imaging guideline medical necessity criteria met; MENINGIOMA - Ga 68 dotatate OR Ga 68 DOTA-TOC PET medically necessary for meningioma, for SUSPECTED RECURRENCE with INCONCLUSIVE findings on MRI, when eviCore oncology imaging guideline medical necessity criteria met; MEDULLARY THYROID CANCER - Ga 68 dotatate OR Ga 68 DOTA-TOC PET medically necessary for RESTAGING medullary thyroid cancer, for INCONCLUSIVE findings on conventional imaging, when eviCore oncology imaging guideline medical necessity criteria met; BREAST - Cerianna (fluoroestradiol F-18) PET medically necessary for detection of estrogen receptor (ER)-positive lesions as an ADJUNCT TO BIOPSY in RECURRENT or METASTATIC breast cancer when eviCore oncology imaging guideline medical necessity criteria met; NEUROLOGY (Alzheimer/cognitive) - Amyloid PET scan (florbetapir F18 [Amyvid], florbetaben F18 [Neuraceq], flortaucipir F18 [Tauvid], flutemetamol F18 [Vizamyl]) medically necessary for persons with mild cognitive impairment due to Alzheimer disease who are being considered for aducanumab (Aduhelm), lecanemab-irmb (Leqembi), OR donanemab-azbt (Kisunla) therapy; NEUROLOGY (epilepsy) - FDG-PET medically necessary ONLY for pre-surgical evaluation for the purpose of localization of a focus of refractory seizure activity; PET/CT FUSION - considered medically necessary for ANY indication where PET scanning is considered medically necessary; OTHER non-oncologic - FDG-PET for diagnosis, staging, and restaging of Langerhans cell histiocytosis; OTHER non-oncologic - FDG-PET for evaluation of large-vessel vasculitis (including giant cell arteritis and Takayasu arteritis) WHEN diagnosis is uncertain FOLLOWING NEGATIVE temporal artery biopsy results; OTHER non-oncologic - FDG-PET for staging and restaging of Erdheim-Chester disease; OTHER non-oncologic - FDG-PET for staging and restaging of hemangiopericytoma; OTHER non-oncologic - FDG-PET for staging, restaging, and surveillance of Rosai-Dorfman disease; OTHER non-oncologic - FDG-PET for workup of monoclonal gammopathy of undetermined significance (MGUS) IF CT/MRI are negative. Applies to 13 codes: 78811, 78812, 78813, 78814, 78815, 78816, 78429, 78430, 78431, 78432, 78459, 78491, 78492. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Precertification may be required for select procedures and interventions. Use the CPT code search tool to see if precertification is required. Many oncologic indications are adjudicated against eviCore oncology imaging guidelines. Policy exclusions and limitations: ONCOLOGY SURVEILLANCE - PET for post-treatment surveillance is experimental, investigational, or unproven (surveillance = use of PET beyond completion of treatment, in the ABSENCE of signs or symptoms of cancer recurrence or progression, for the purpose of detecting recurrence/progression or predicting outcome); AMYLOID PET - experimental/investigational for sporadic cerebral amyloid angiopathy; AMYLOID PET - florbetapir-PET experimental/investigational for cerebral amyloid angiopathy-related hemorrhages; Carbon-11 labeled 5-HTP PET - experimental/investigational for carcinoid and all other indications; FDG-PET non-oncologic - experimental/investigational for adrenoleukodystrophy; FDG-PET non-oncologic - experimental/investigational for chronic osteomyelitis; FDG-PET non-oncologic - experimental/investigational for coccidioidomycosis; FDG-PET non-oncologic - experimental/investigational for cortico-basal syndrome; FDG-PET non-oncologic - experimental/investigational for eosinophilia; FDG-PET non-oncologic - experimental/investigational for fever of unknown origin; FDG-PET non-oncologic - experimental/investigational for hepatic encephalopathy; FDG-PET non-oncologic - experimental/investigational for knee replacement prostheses infection; FDG-PET non-oncologic - experimental/investigational for hip arthroplasty infection; FDG-PET non-oncologic - experimental/investigational for joint infection; FDG-PET non-oncologic - experimental/investigational for osteoarthritis joint inflammation; FDG-PET non-oncologic - experimental/investigational for lymphangiomatosis; FDG-PET non-oncologic - experimental/investigational for mesenteric lymphadenopathy; FDG-PET non-oncologic - experimental/investigational for Moyamoya disease; FDG-PET non-oncologic - experimental/investigational for Parkinson disease neurodegenerative progression; FDG-PET non-oncologic - experimental/investigational for opsoclonus myoclonus syndrome; FDG-PET non-oncologic - experimental/investigational for pigmented villonodular synovitis; FDG-PET non-oncologic - experimental/investigational for pleural effusion; FDG-PET non-oncologic - experimental/investigational for rheumatoid arthritis; FDG-PET non-oncologic - experimental/investigational for sarcoidosis (EXCEPT cardiac sarcoidosis, which is medically necessary); FDG-PET non-oncologic - experimental/investigational for Li-Fraumeni screening; FDG-PET non-oncologic - experimental/investigational for splenomegaly; FDG-PET non-oncologic - experimental/investigational for Takayasu's arteritis (as a standalone non-oncologic indication outside the covered large-vessel vasculitis post-negative-biopsy criterion); FDG-PET non-oncologic - experimental/investigational for xanthogranuloma; FDG-PET non-oncologic - experimental/investigational for all other unlisted non-oncologic indications; FDG-PET oncologic - experimental/investigational for amyloidosis follow-up in transplant recipients; FDG-PET oncologic - experimental/investigational for atypical teratoid/rhabdoid tumor; FDG-PET oncologic - experimental/investigational for chondrosarcoma; FDG-PET oncologic - experimental/investigational for clear cell carcinoma of the uterus; FDG-PET oncologic - experimental/investigational for desmoid tumors; FDG-PET oncologic - experimental/investigational for endometrial cancer; FDG-PET oncologic - experimental/investigational for intraductal papillary mucinous neoplasm of the pancreas; FDG-PET oncologic - experimental/investigational for gestational trophoblastic neoplasia; FDG-PET oncologic - experimental/investigational for giant cell tumor of bone; FDG-PET oncologic - experimental/investigational for hemangioendothelioma; FDG-PET oncologic - experimental/investigational for hepatic sarcoma; FDG-PET oncologic - experimental/investigational for hepatocellular carcinoma; FDG-PET oncologic - experimental/investigational for hypercalcemia of malignancy; FDG-PET oncologic - experimental/investigational for kidney cancer; FDG-PET oncologic - experimental/investigational for leukemia; FDG-PET oncologic - experimental/investigational for malignant neurofibromas; FDG-PET oncologic - experimental/investigational for neurofibromatosis; FDG-PET oncologic - experimental/investigational for neuroganglioma of the psoas; FDG-PET oncologic - experimental/investigational for osteoblastoma; FDG-PET oncologic - experimental/investigational for Paget's disease; FDG-PET oncologic - experimental/investigational for peri-ampullary cancer; FDG-PET oncologic - experimental/investigational for pilar tumor; FDG-PET oncologic - experimental/investigational for pituitary adenoma; FDG-PET oncologic - experimental/investigational for placental cancer; FDG-PET oncologic - experimental/investigational for plasmacytoid dendritic cell neoplasm; FDG-PET oncologic - experimental/investigational for pleomorphic adenoma; FDG-PET oncologic - experimental/investigational for schwannoma; FDG-PET oncologic - experimental/investigational for salivary gland tumors; FDG-PET oncologic - experimental/investigational for serous papillary endometrial carcinoma; FDG-PET oncologic - experimental/investigational for solitary fibrous tumors; FDG-PET oncologic - experimental/investigational for spindle cell sarcoma; FDG-PET oncologic - experimental/investigational for surgical planning of PEComas; FDG-PET oncologic - experimental/investigational for sweat gland tumor; FDG-PET oncologic - experimental/investigational for uterine papillary mesothelioma; FDG-PET oncologic - experimental/investigational for Waldenstrom macroglobulinemia restaging; FDG-PET oncologic - experimental/investigational for Wilms tumor; FDG-PET oncologic - experimental/investigational for all other unlisted oncologic indications; 11C-choline PET - experimental/investigational for hyperparathyroidism; 11C-metomidate PET - experimental/investigational for monitoring primary aldosteronism treatment response; 18F-FDOPA-PET - experimental/investigational for brain cancer prognosis; Fluorodopa F-18 PET - experimental/investigational for Parkinsonian syndromes / Parkinson disease; Ga-68 dotatate - experimental/investigational for SDHB mutation monitoring; NaF-18 (sodium fluoride F-18) PET - experimental/investigational for bone metastasis and other indications; PET - experimental/investigational for disseminated histoplasmosis imaging; PET - experimental/investigational for hepatoblastoma imaging; PET - experimental/investigational for SIRT (selective internal radiation therapy) planning, or for evaluation of abnormal CT after dermatofibrosarcoma resection; PET-probe guided surgical resection - experimental/investigational for recurrent ovarian cancer; PET - experimental/investigational for Huntington disease; PET - experimental/investigational for asymptomatic screening for breast, lung, or other cancers; PET/CT - experimental/investigational for monitoring littoral cell splenic angioma; PET/MRI - experimental/investigational for ALL indications (exceptions to cover PET/MRI may be made where PET/CT is unavailable and medical necessity criteria for FDG-PET are met); Gamma camera PET scanning - experimental/investigational; Positron emission mammography - experimental/investigational; SCINTIX biology-guided radiotherapy - experimental/investigational; PET - experimental/investigational for evaluation of unspecified periodic fever syndrome; FDG-PET as an alternative to 99mTc skeletal scintigraphy (bone scan) - NO LONGER acceptable: there is no longer a temporary shortage of technetium 99-m, therefore Aetna will no longer consider FDG-PET an acceptable alternative to bone scans. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Positron Emission Tomography (PET)?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Precertification may be required for select procedures and interventions. Use the CPT code search tool to see if precertification is required. Many oncologic indications are adjudicated against eviCore oncology imaging guidelines.
What does Aetna exclude for Positron Emission Tomography (PET)?
Policy exclusions and limitations: ONCOLOGY SURVEILLANCE - PET for post-treatment surveillance is experimental, investigational, or unproven (surveillance = use of PET beyond completion of treatment, in the ABSENCE of signs or symptoms of cancer recurrence or progression, for the purpose of detecting recurrence/progression or predicting outcome); AMYLOID PET - experimental/investigational for sporadic cerebral amyloid angiopathy; AMYLOID PET - florbetapir-PET experimental/investigational for cerebral amyloid angiopathy-related hemorrhages; Carbon-11 labeled 5-HTP PET - experimental/investigational for carcinoid and all other indications; FDG-PET non-oncologic - experimental/investigational for adrenoleukodystrophy; FDG-PET non-oncologic - experimental/investigational for chronic osteomyelitis; FDG-PET non-oncologic - experimental/investigational for coccidioidomycosis; FDG-PET non-oncologic - experimental/investigational for cortico-basal syndrome; FDG-PET non-oncologic - experimental/investigational for eosinophilia; FDG-PET non-oncologic - experimental/investigational for fever of unknown origin; FDG-PET non-oncologic - experimental/investigational for hepatic encephalopathy; FDG-PET non-oncologic - experimental/investigational for knee replacement prostheses infection; FDG-PET non-oncologic - experimental/investigational for hip arthroplasty infection; FDG-PET non-oncologic - experimental/investigational for joint infection; FDG-PET non-oncologic - experimental/investigational for osteoarthritis joint inflammation; FDG-PET non-oncologic - experimental/investigational for lymphangiomatosis; FDG-PET non-oncologic - experimental/investigational for mesenteric lymphadenopathy; FDG-PET non-oncologic - experimental/investigational for Moyamoya disease; FDG-PET non-oncologic - experimental/investigational for Parkinson disease neurodegenerative progression; FDG-PET non-oncologic - experimental/investigational for opsoclonus myoclonus syndrome; FDG-PET non-oncologic - experimental/investigational for pigmented villonodular synovitis; FDG-PET non-oncologic - experimental/investigational for pleural effusion; FDG-PET non-oncologic - experimental/investigational for rheumatoid arthritis; FDG-PET non-oncologic - experimental/investigational for sarcoidosis (EXCEPT cardiac sarcoidosis, which is medically necessary); FDG-PET non-oncologic - experimental/investigational for Li-Fraumeni screening; FDG-PET non-oncologic - experimental/investigational for splenomegaly; FDG-PET non-oncologic - experimental/investigational for Takayasu's arteritis (as a standalone non-oncologic indication outside the covered large-vessel vasculitis post-negative-biopsy criterion); FDG-PET non-oncologic - experimental/investigational for xanthogranuloma; FDG-PET non-oncologic - experimental/investigational for all other unlisted non-oncologic indications; FDG-PET oncologic - experimental/investigational for amyloidosis follow-up in transplant recipients; FDG-PET oncologic - experimental/investigational for atypical teratoid/rhabdoid tumor; FDG-PET oncologic - experimental/investigational for chondrosarcoma; FDG-PET oncologic - experimental/investigational for clear cell carcinoma of the uterus; FDG-PET oncologic - experimental/investigational for desmoid tumors; FDG-PET oncologic - experimental/investigational for endometrial cancer; FDG-PET oncologic - experimental/investigational for intraductal papillary mucinous neoplasm of the pancreas; FDG-PET oncologic - experimental/investigational for gestational trophoblastic neoplasia; FDG-PET oncologic - experimental/investigational for giant cell tumor of bone; FDG-PET oncologic - experimental/investigational for hemangioendothelioma; FDG-PET oncologic - experimental/investigational for hepatic sarcoma; FDG-PET oncologic - experimental/investigational for hepatocellular carcinoma; FDG-PET oncologic - experimental/investigational for hypercalcemia of malignancy; FDG-PET oncologic - experimental/investigational for kidney cancer; FDG-PET oncologic - experimental/investigational for leukemia; FDG-PET oncologic - experimental/investigational for malignant neurofibromas; FDG-PET oncologic - experimental/investigational for neurofibromatosis; FDG-PET oncologic - experimental/investigational for neuroganglioma of the psoas; FDG-PET oncologic - experimental/investigational for osteoblastoma; FDG-PET oncologic - experimental/investigational for Paget's disease; FDG-PET oncologic - experimental/investigational for peri-ampullary cancer; FDG-PET oncologic - experimental/investigational for pilar tumor; FDG-PET oncologic - experimental/investigational for pituitary adenoma; FDG-PET oncologic - experimental/investigational for placental cancer; FDG-PET oncologic - experimental/investigational for plasmacytoid dendritic cell neoplasm; FDG-PET oncologic - experimental/investigational for pleomorphic adenoma; FDG-PET oncologic - experimental/investigational for schwannoma; FDG-PET oncologic - experimental/investigational for salivary gland tumors; FDG-PET oncologic - experimental/investigational for serous papillary endometrial carcinoma; FDG-PET oncologic - experimental/investigational for solitary fibrous tumors; FDG-PET oncologic - experimental/investigational for spindle cell sarcoma; FDG-PET oncologic - experimental/investigational for surgical planning of PEComas; FDG-PET oncologic - experimental/investigational for sweat gland tumor; FDG-PET oncologic - experimental/investigational for uterine papillary mesothelioma; FDG-PET oncologic - experimental/investigational for Waldenstrom macroglobulinemia restaging; FDG-PET oncologic - experimental/investigational for Wilms tumor; FDG-PET oncologic - experimental/investigational for all other unlisted oncologic indications; 11C-choline PET - experimental/investigational for hyperparathyroidism; 11C-metomidate PET - experimental/investigational for monitoring primary aldosteronism treatment response; 18F-FDOPA-PET - experimental/investigational for brain cancer prognosis; Fluorodopa F-18 PET - experimental/investigational for Parkinsonian syndromes / Parkinson disease; Ga-68 dotatate - experimental/investigational for SDHB mutation monitoring; NaF-18 (sodium fluoride F-18) PET - experimental/investigational for bone metastasis and other indications; PET - experimental/investigational for disseminated histoplasmosis imaging; PET - experimental/investigational for hepatoblastoma imaging; PET - experimental/investigational for SIRT (selective internal radiation therapy) planning, or for evaluation of abnormal CT after dermatofibrosarcoma resection; PET-probe guided surgical resection - experimental/investigational for recurrent ovarian cancer; PET - experimental/investigational for Huntington disease; PET - experimental/investigational for asymptomatic screening for breast, lung, or other cancers; PET/CT - experimental/investigational for monitoring littoral cell splenic angioma; PET/MRI - experimental/investigational for ALL indications (exceptions to cover PET/MRI may be made where PET/CT is unavailable and medical necessity criteria for FDG-PET are met); Gamma camera PET scanning - experimental/investigational; Positron emission mammography - experimental/investigational; SCINTIX biology-guided radiotherapy - experimental/investigational; PET - experimental/investigational for evaluation of unspecified periodic fever syndrome; FDG-PET as an alternative to 99mTc skeletal scintigraphy (bone scan) - NO LONGER acceptable: there is no longer a temporary shortage of technetium 99-m, therefore Aetna will no longer consider FDG-PET an acceptable alternative to bone scans. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0071 — Positron Emission Tomography (PET)

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0071 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.