CommercialPrior AuthHigh impact
Positron Emission Tomography (PET) (CPB 0071, reviewed 2026-07-28)
Aetna·Cardiology, Oncology, Neurology +2 more·Medical Policy
Effective date
Jul 28, 2026
We identified it
Aug 13, 2026
Summary
Aetna has updated its PET imaging policy (CPB 0071, effective 2026-07-28) to clarify medical necessity criteria across cardiac, oncologic, and neurologic indications. Key updates include expanded coverage for cardiac PET with absolute quantitation of myocardial blood flow (AQMBF), refined criteria for amyloid/tau PET monitoring in Alzheimer's disease patients on FDA-approved therapies, and references to EviCore guidelines for oncologic indications. Precertification may be required for select procedures.
Action Required
By 2026-07-28: (1) Billing team must review precertification requirements using Aetna's CPT code search tool for all PET procedures covered under this policy; (2) Update billing software and encounter forms to reflect new medical necessity criteria, particularly for cardiac PET with AQMBF and amyloid PET monitoring intervals (6, 12, 18 months for donanemab; 18+ months for lecanemab); (3) Educate providers on documentation requirements for cardiac indications (CAD evaluation, viability assessment, sarcoidosis, AQMBF justification) and neurologic indications (diagnostic uncertainty, specific clinical presentations, treatment eligibility); (4) Establish precertification workflow requiring prior authorization for select PET codes before claim submission; (5) Ensure oncology billing references EviCore guidelines for FDG-PET approval criteria. Failure to obtain precertification will result in claim denials. Update referral templates and prior auth submission processes immediately.