Why Aetna Denies PET/CT Scan
Staging not appropriate for tumor type
Follow-up scan too soon after treatment
Diagnosis does not meet NCD criteria
Know Aetna's Criteria
Aetna uses their own Clinical Policy Bulletins (CPBs) and InterQual criteria. CPBs are publicly available and numbered.
Key policies to know:
- Clinical Policy Bulletins (CPBs) are publicly available and numbered
- Uses eviCore for radiology and cardiology prior auth
- Known for detailed, evidence-based CPBs with specific criteria
- Precertification list updated annually
Aetna's Specific Approach to PET/CT Scan
Applicable Policy
Aetna CPB 0071 (Positron Emission Tomography)
How Aetna Typically Denies This
Aetna CPB 0071 is very detailed with specific cancer types and clinical scenarios. They list covered indications by tumor type. Unlisted tumors or indications require individual review.
Your Strategy for This Payer
Find your exact tumor type and clinical scenario in CPB 0071. If it's listed as covered, cite the specific section. If it's not explicitly listed, cite published evidence supporting PET for that indication.
Key Phrase to Use on the Call
"Per CPB 0071, PET/CT for [specific indication] in [cancer type] is a covered indication. The patient meets the clinical criteria specified in section [X] of the CPB."
Building Your Medical Necessity Argument
Reference the specific NCD indication being met
Document how PET results will change management
Note prior imaging results that are insufficient
Cite NCCN guideline recommendation for PET at this stage
P2P Call Tips for Aetna
Reference the specific CPB number and criteria being met
Aetna CPBs are very detailed -- read them before the call
Address each specific criterion in the CPB during the P2P
Aetna medical directors are typically receptive to guideline-based arguments
Guidelines to Reference
- CMS National Coverage Determination for FDG PET
- NCCN Guidelines by cancer type
Relevant CPT Codes
Specialty: Oncology / Pulmonology
Want the full strategy?
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