Medicare AdvantageCoverageMedium impact
Nuclear Imaging for Noncancer Indications - Medicare Advantage (Revised)
Humana·Nuclear Medicine, Radiology, Neurology +2 more·Medicare Advantage
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicare Advantage revised its Nuclear Imaging for Noncancer Indications policy effective July 1, 2026, establishing updated medical necessity criteria for FDG PET, PET/CT, and Beta Amyloid PET imaging. For jurisdictions without local coverage determinations, the policy now references LCD L39521 criteria for inflammation/infection cases, and establishes specific diagnostic requirements for Alzheimer's disease amyloid imaging including provider experience, blood work, imaging, and documentation that results will influence treatment.
Action Required
Before July 1, 2026: Billing and clinical teams must review and implement the updated medical necessity criteria for nuclear imaging claims. (1) Update billing system edits to enforce prior authorization requirements for FDG PET (78608, 78811, 78812, 78813) and PET/CT (78814, 78815, 78816) for noncancer indications. (2) For Alzheimer's disease amyloid PET/PET/CT claims, ensure providers document: evaluation by dementia-experienced provider (neurologist/geriatrician), blood tests ruling out reversible causes, detailed medical/neurobehavioral history, mental status testing, physical exam, and structural brain imaging (CT/MRI). (3) Verify that clinical documentation demonstrates how imaging results will influence treatment decisions. (4) For inflammation/infection cases in jurisdictions without local LCDs, apply criteria from LCD L39521. (5) Communicate these requirements to all ordering providers. Failure to obtain proper documentation and medical necessity support will result in claim denials.