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HumanaCommercial Clinical Policy

Humana Fusion Imaging for Cancer Indications Form


PET/CT

Notes: Coverage is denied for experimental/investigational uses not widely accepted in peer-reviewed medical literature.

Indications

(700867) Is the PET/CT procedure being considered for an indication other than those listed as covered? 

Contraindications

(700868) Is the PET/CT procedure being used for evaluation of prostate, gastric, or testicular cancer, initial diagnosis or staging of axillary lymph nodes in breast cancer and melanoma, initial staging of colorectal cancer (except in individuals with a contrast allergy), or routine monitoring following small cell lung cancer treatment? 
(700869) Is the PET/CT procedure a total body scan (uEXPLORER) for screening purposes? 

SPECT/CT

Notes: Coverage is denied for experimental/investigational uses not widely accepted in peer-reviewed medical literature.

Indications

(700870) Is the SPECT/CT procedure being considered for an indication other than that listed as covered? 

Other Fusion Imaging Procedures

Notes: Coverage is denied for experimental/investigational uses not widely accepted in peer-reviewed medical literature.

Indications

(700871) Is the fusion imaging procedure being considered one of the following: CAD with MRI for prostate biopsy (DynaCAD), CAD with ultrasound for prostate biopsy (Fusion Bx 2.0), diagnostic CT scan with PET/CT, MRI/CT, PET/MRI, SeeFactor CT3, or SPECT/MRI? 

YesNoN/A
YesNoN/A

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Effective Date

06/22/2023

Last Reviewed

NA

Original Document

  Reference



Fusion Imaging for Cancer Indications

Medical Coverage Policy

Effective Date: 06/22/2023
Revision Date: N/A
Review Date: 06/22/2023

Policy Number: HUM-0618-000

Change Summary: New Policy

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

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