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 updated medical necessity criteria across cardiac and oncologic indications before submitting claims against CPT codes 78429–78492, 78608, 78609, 78811–78816, and a broad set of HCPCS radiopharmaceutical codes.

Aetna's CPB 0071 Aetna system update touches one of the most code-dense imaging policies in outpatient billing — 56 CPT codes, 47 HCPCS codes, and over 1,500 ICD-10-CM diagnosis codes. PET scan billing has always been a denial-risk area because coverage is highly indication-specific and radiopharmaceutical selection directly determines whether a claim pays. This update tightens the criteria in ways that will trip up teams who haven't read the full policy since the last revision.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Positron Emission Tomography (PET) — CPB 0071
Policy Code	CPB 0071
Change Type	Modified
Effective Date	December 17, 2025
Impact Level	High
Specialties Affected	Cardiology, Nuclear Medicine, Radiology, Oncology, Neurology, Thoracic Surgery
Key Action	Audit charge capture for cardiac PET codes 78429–78492 and all HCPCS radiopharmaceutical codes against updated selection criteria before billing

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Aetna PET Scan Coverage Criteria and Medical Necessity Requirements 2025

Aetna's PET scan coverage policy splits into two major categories: cardiac indications and oncologic indications. Each has its own medical necessity rules. Getting them confused is one of the fastest ways to generate a claim denial.

Cardiac Indications

For coronary artery disease, Aetna covers PET using rubidium-82 (Rb-82, HCPCS A9555) or N-13 ammonia (HCPCS A9526) at rest or with pharmacological stress. CPT codes 78430, 78431, 78491, and 78492 apply here. Coverage requires one of two conditions: the PET replaces — not supplements — a SPECT scan for a member who meets SPECT medical necessity criteria under CPB 0376, or the study assesses coronary artery disease after cardiac transplant.

That "in place of, not in addition to" language is the real issue. If your ordering provider runs both a SPECT and a PET on the same patient for the same indication, the PET will not meet medical necessity. Train your pre-authorization team to flag these dual-study orders before they hit your charge capture.

Aetna also covers absolute quantitation of myocardial blood flow (AQMBF) via add-on CPT +78434 as a medically necessary adjunct — but only when the underlying rest/stress perfusion study already meets criteria. You cannot bill +78434 standalone.

For myocardial viability, FDG-PET (CPT 78429, 78432, 78433, 78459; HCPCS A9552) is covered prior to revascularization. It can serve as the primary diagnostic study or as follow-up to an inconclusive SPECT. One important note: Aetna explicitly states that a SPECT following an inconclusive PET is not medically necessary. The greater specificity of PET makes the follow-up SPECT redundant under this policy. If you see orders structured that way, flag them before billing.

Cardiac sarcoid is a covered indication. Aetna covers FDG-PET (A9552) to identify and monitor treatment response for established or strongly suspected cardiac sarcoid.

Oncologic Indications

For oncology, Aetna defers to eviCore Oncology Imaging Guidelines and eviCore Pediatric and Special Populations Oncology Imaging Guidelines. This is an important structural point for your billing team: Aetna itself does not publish the oncology medical necessity criteria in CPB 0071. The criteria live in eviCore's guidelines, which update on their own schedule.

The covered oncologic tumor types under this policy are extensive. They include adrenal carcinoma, adrenocortical tumors, anal cancer, brain tumors, breast cancer, Burkitt's lymphoma, cervical cancer, chordoma, chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) with suspected Richter's transformation, and many more. For oncologic PET billing, CPT 78811 (limited area), 78812 (skull base to mid-thigh), 78813 (whole body), 78814, 78815, and 78816 (PET/CT combinations) are the primary procedure codes.

Prior authorization is likely required for many of these studies. Use Aetna's CPT code search tool to confirm precertification requirements before scheduling, not after.

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Aetna PET Scan Exclusions and Non-Covered Indications

Several HCPCS radiopharmaceutical codes are explicitly not covered under CPB 0071, regardless of indication. These are worth building into your charge capture edits.

A9586 (Florbetapir F-18) is listed as not covered for indications in this CPB. Florbetapir is an amyloid PET tracer. If your neurology or memory disorder practice bills amyloid PET studies, this is a high-risk code for claim denial under Aetna.

A9591 (Fluoroestradiol F-18) is not covered. This tracer is used in breast cancer staging for estrogen receptor status. Even if the underlying oncologic indication appears on the covered list, the radiopharmaceutical selection matters.

A9597 and A9598 — the "not otherwise specified" radiopharmaceutical codes for tumor and non-tumor identification — are not covered. Aetna wants specificity. If you're using NOC codes because you can't get a specific HCPCS code assigned, expect denials.

A9602 (Fluorodopa F-18) is not covered under this CPB. This tracer is used in Parkinson's disease and neuroendocrine tumor imaging.

The practical takeaway: radiopharmaceutical selection is not just a clinical decision. It determines reimbursement. Your charge capture team and your clinical staff need to communicate about tracer choice before the study is performed.

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Coverage Indications at a Glance

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Aetna PET Scan Billing Guidelines and Action Items 2025

These are direct action items for your billing and revenue cycle teams. Tie them to the December 17, 2025 effective date.

Copy Action Items

If you're unsure how this policy interacts with your specific patient population or mix of oncologic indications, talk to your compliance officer before the December 17, 2025 effective date.

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

Covered CPT Codes — Directly Covered for Listed Indications

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

Covered CPT Codes — When Selection Criteria Are Met

Other CPT Codes Related to CPB 0071

Covered HCPCS Codes — When Selection Criteria Are Met

Not Covered HCPCS Codes

Key ICD-10-CM Diagnosis Codes

CPB 0071 maps to over 1,500 ICD-10-CM codes. The full list is available in the Aetna source policy. Cross-reference your diagnosis codes against the complete policy list before submission — a covered CPT with an unsupported ICD-10 code generates a denial just as surely as a missing prior authorization.

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