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HumanaCommercial Clinical Policy

Humana Fusion Imaging for Cancer Indications Form


PET/CT

Notes: Coverage for PET with concurrently acquired CT is limited and is not considered covered for the scenarios listed.


Contraindications

(700867) Is the PET/CT for the evaluation of the initial diagnosis or staging of axillary lymph nodes in breast cancer and melanoma? 
(700868) Is the PET/CT for routine monitoring following small cell lung cancer treatment? 
(700869) Is this a Total body PET/CT (uEXPLORER) for screening? 

SPECT/CT

Notes: Coverage for SPECT with concurrently acquired CT is limited and is not generally accepted for any proposed use not listed above.


Contraindications

(700870) Is this SPECT/CT usage not previously mentioned in the covered indications? 

Fusion Imaging Procedures

Notes: These specific fusion imaging procedures are generally considered experimental/investigational and are not covered.


Contraindications

(700871) Is CAD being used in conjunction with MRI for prostate biopsy? 
YesNoN/A
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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