Does Humana require prior authorization for CPT 78816?

Yes. Humana requires prior authorization for CPT 78816 (PET scan with CT of the full body for tumor detection) under Standard commercial plans per its published clinical policy.

What documentation does Humana require for CPT 78816?

Pathology report; Conventional imaging; Clinical notes from oncologist; Treatment plan

What if Humana denies the PA for CPT 78816?

Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Prior Authorization

Humana Prior Authorization for CPT 78816

PET scan with CT of the full body for tumor detection · Standard commercial plans

Prior authorization REQUIREDApplies to all statesLast verified January 1, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Humana Commercial Preauthorization and Notification List (July 2024)

Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.

Clinical criteria

Humana requires prior authorization for PET/CT. Approved for initial staging of histologically confirmed malignancy, restaging or suspected recurrence, treatment response evaluation, and characterization of indeterminate pulmonary nodule. Follow NCD 220.6.17 criteria for Medicare Advantage. Not approved for screening or routine post-treatment surveillance without clinical suspicion.

Documentation checklist

✓Pathology report
✓Conventional imaging
✓Clinical notes from oncologist
✓Treatment plan

Submission channels

Phone

1-800-444-9137

Fax

1-877-418-0506

2026 Medicare rate for CPT 78816

CPT 78816 is not priced under the 2026 Medicare Physician Fee Schedule (status C) — drugs/biologicals price under ASP and lab tests under the CLFS. See the CPT 78816 code page for pricing detail.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Pathology report, Conventional imaging, Clinical notes from oncologist….
3Submit via phone or fax, or the payer portal.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Humana require prior authorization for CPT 78816?: Yes. Humana requires prior authorization for CPT 78816 (PET scan with CT of the full body for tumor detection) under Standard commercial plans per its published clinical policy.
What documentation does Humana require for CPT 78816?: Pathology report; Conventional imaging; Clinical notes from oncologist; Treatment plan
What if Humana denies the PA for CPT 78816?: Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Other Humana PA lookups

CPT 70450 CPT 72148 CPT 73721 CPT 74177 CPT 73221 CPT 76641 CPT 76942 CPT 70551

All Humana prior-authorization requirements →

CPT 78816 prior authorization by payer

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