Why Anthem BCBS Denies PET/CT Scan
Staging not appropriate for tumor type
Follow-up scan too soon after treatment
Diagnosis does not meet NCD criteria
Know Anthem / Blue Cross Blue Shield's Criteria
Anthem uses their own Clinical UM Guidelines and AIM Specialty Health for imaging. Medical policy numbers are publicly searchable.
Key policies to know:
- AIM Specialty Health manages imaging prior auth
- Clinical UM Guidelines searchable at anthem.com/provider
- Known for strict imaging prior auth requirements
- Uses evidence-based medicine approach with published policies
Anthem BCBS's Specific Approach to PET/CT Scan
Applicable Policy
Anthem Radiology Policy RAD.00025 (PET/CT Imaging)
How Anthem BCBS Typically Denies This
Anthem often denies PET for surveillance or routine follow-up. They require documentation of how the PET result will change the treatment plan. For restaging, they want evidence of clinical or imaging suspicion of recurrence.
Your Strategy for This Payer
Lead with the clinical decision that depends on the PET result. Anthem wants to know: 'If the PET is positive, what will you do differently? If negative, what changes?'
Key Phrase to Use on the Call
"A positive PET will prompt [biopsy/treatment change/surgical planning], while a negative result will allow [continued surveillance/treatment completion], making this study essential for management per RAD.00025."
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 Anthem BCBS
Reference specific Anthem Clinical UM Guideline by policy number
For imaging, address AIM criteria specifically
Anthem medical directors appreciate evidence-based arguments
Cite specific clinical criteria being met from their own policy
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?
The P2P Playbook covers payer-specific approaches for PET/CT Scan denied by Anthem BCBS -- plus 15 denial objections with word-for-word responses, what reviewers are actually thinking, and the 60-second prep framework. Written by a medical director who reviewed cases for major payers.
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