Positron Emission Tomography (PET) — CPB 0071 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0071 governing PET scan coverage policy, effective December 17, 2025. Billing teams need to review cardiac, oncologic, and neurologic indications now — this policy touches 56 CPT codes and 47 HCPCS codes.

---

Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Positron Emission Tomography (PET)
Policy Code	CPB 0071
Change Type	Modified
Effective Date	December 17, 2025
Impact Level	High
Specialties Affected	Cardiology, Nuclear Medicine, Oncology, Neurology, Radiology
Key Action	Audit your PET charge capture against updated cardiac, oncologic, and neurologic criteria before billing claims with effective dates on or after December 17, 2025

---

Aetna PET Scan Coverage Criteria and Medical Necessity Requirements 2025

Aetna's PET scan coverage policy under CPB 0071 splits into three major categories: cardiac, oncologic, and neurologic indications. Each category carries distinct medical necessity requirements. Miss the distinction, and you're looking at a claim denial.

Cardiac Indications

For coronary artery disease, Aetna covers PET using rubidium-82 (Rb-82, billed as HCPCS A9555) or N-13 ammonia (HCPCS A9526) at rest or with pharmacological stress. The key restriction: PET must replace SPECT, not supplement it. If you bill both a cardiac PET (CPT 78491 or 78492) and a SPECT on the same patient for the same indication, expect a denial. The only exception is post-cardiac transplant assessment, where PET is covered regardless of prior SPECT.

Absolute quantitation of myocardial blood flow (AQMBF) using add-on CPT +78434 is covered as an adjunct — but only when the underlying rest/stress perfusion study meets medical necessity criteria first. You can't bill +78434 in isolation.

For myocardial viability, FDG-PET (HCPCS A9552, CPT 78429 or 78459) is covered before re-vascularization. It works as either a primary study or a follow-up to an inconclusive SPECT. One important flip: if the PET itself is inconclusive, Aetna does not consider a subsequent SPECT medically necessary. The PET's greater specificity ends the diagnostic chain.

Cardiac sarcoid is also covered. FDG-PET is medically necessary to identify and monitor treatment response for established or strongly suspected cardiac sarcoid. This is a clear, covered indication — bill it with confidence when clinical documentation supports it.

Oncologic Indications

This is where PET billing volume is highest for most practices. Aetna defers to eviCore Oncology Imaging Guidelines for oncologic FDG-PET coverage decisions. That's a meaningful operational detail. Prior authorization for oncologic PET scans is governed by eviCore criteria — confirm the specific submission pathway using Aetna's CPT code search tool before submitting.

The covered oncologic indications list is extensive. It includes breast cancer, brain tumors, cervical cancer, Burkitt's lymphoma, CLL/SLL with suspected Richter's transformation, Castleman's disease, chordoma, adrenal carcinoma, adrenocortical tumors, anal cancer, ampullary cancer, appendiceal cancer, and more. The full eviCore guidelines govern the specifics. Pull those guidelines before submitting prior authorization requests — eviCore updates them annually and can change criteria without advance notice beyond a 90-day draft posting.

CPT codes 78811–78816 are the workhorse codes here. Use 78811 for limited area imaging, 78812 for skull base to mid-thigh, and 78813 for whole body. Add the CT attenuation correction suffix codes 78814–78816 when a concurrent CT is performed.

Neurologic Indications

CPT 78608 (metabolic evaluation) and 78609 (perfusion evaluation) cover brain PET imaging for indications listed in CPB 0071. Refer to the full policy document for the complete list of covered neurologic indications and their specific medical necessity criteria, as that section was not fully reproduced here.

Prior Authorization

Aetna requires precertification for select PET procedures. Use Aetna's CPT code search tool to confirm whether prior authorization applies before you schedule. Don't assume coverage equals no auth requirement. For oncologic PET, Aetna's coverage criteria are governed by eviCore Oncology Imaging Guidelines. Confirm the specific prior authorization submission pathway — whether through Aetna's portal or eviCore directly — using Aetna's CPT code search tool before submitting.

---

Aetna PET Scan Exclusions and Non-Covered Indications

Several HCPCS codes are explicitly not covered under this coverage policy, regardless of clinical indication.

Florbetapir F-18 (A9586) for amyloid PET imaging is not covered. This is used for Alzheimer's workup, and Aetna's position here is clear — don't bill it expecting reimbursement.

Fluoroestradiol F-18 (A9591) for breast cancer receptor imaging is not covered under CPB 0071. This one generates denials regularly at practices billing it under PET for breast cancer staging.

A9597 and A9598 — the catch-all radiopharmaceutical codes for tumor and non-tumor identification not otherwise specified — are not covered. If you're using these as a workaround for a tracer that lacks its own HCPCS code, stop. Aetna won't pay them.

Fluorodopa F-18 (A9602) is not covered for any indication listed in CPB 0071.

The real issue here is that practices sometimes default to unspecified radiopharmaceutical codes when the specific HCPCS code is unclear. This policy makes it explicit: use the specific code or don't bill it. Review your charge capture setup to make sure no one is defaulting to A9597 or A9598 out of habit.

---

Coverage Indications at a Glance

---

Aetna PET Scan Billing Guidelines and Action Items 2025

Copy Action Items

If you have a high volume of Aetna PET claims — particularly in cardiology or oncology — loop in your compliance officer before the effective date to review your internal policies against CPB 0071. The interaction between cardiac PET, SPECT substitution rules, and eviCore oncology criteria creates real audit exposure if your documentation protocols haven't kept pace.

---

CPT, HCPCS, and ICD-10 Codes for PET Scans Under CPB 0071

Covered CPT Codes — Brain PET

Code	Description Copy
78608	Brain imaging, PET; metabolic evaluation
78609	Brain imaging, PET; perfusion evaluation

Covered CPT Codes — Cardiac PET (When Selection Criteria Are Met)

Covered CPT Codes — Oncologic and General PET (When Selection Criteria Are Met)

Covered HCPCS Codes — Radiopharmaceuticals (When Selection Criteria Are Met)

Non-Covered HCPCS Codes

ICD-10-CM Codes

This policy maps to 1,573 ICD-10-CM diagnosis codes. The full list is available in the CPB 0071 Aetna policy document. If you bill PET for cardiac, oncologic, or neurologic indications, confirm your primary diagnosis codes are on Aetna's covered list before submitting. A diagnosis code mismatch is one of the most common PET claim denial triggers.

---