Tumor Scintigraphy — CPB 0168 | AETNA Coverage Update

Aetna modified CPB 0168 covering tumor scintigraphy, effective October 7, 2025. Here's what billing teams need to know.

Aetna, a CVS Health company, updated its tumor scintigraphy coverage policy under CPB 0168 in the Aetna system. This policy governs nuclear medicine imaging procedures across oncology, including ProstaScint, OctreoScan, CEA-Scan, and Tc-99m-sestamibi scans. Primary affected codes include CPT 78800–78804, 78830–78832, and HCPCS A9500, A9507, A9508, A9568, A9572, and A9590. If your practice bills any of these for cancer staging or recurrence detection, review your charge capture and documentation workflows before October 7, 2025.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Tumor Scintigraphy
Policy Code	CPB 0168
Change Type	Modified
Effective Date	October 7, 2025
Impact Level	High
Specialties Affected	Nuclear Medicine, Oncology, Urology, Colorectal Surgery, Endocrinology, Breast Surgery
Key Action	Audit documentation for each covered indication and verify correct HCPCS radiopharmaceutical codes before submitting claims after October 7, 2025

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Aetna Tumor Scintigraphy Coverage Criteria and Medical Necessity Requirements 2025

The Aetna tumor scintigraphy coverage policy under CPB 0168 covers several distinct radiopharmaceutical imaging agents. Each has its own medical necessity criteria. They are not interchangeable. Billing the wrong agent code against the wrong diagnosis will get your claim denied.

ProstaScint (HCPCS A9507 — Indium In-111 capromab pendetide)

Aetna covers ProstaScint scans under two indications. First, pre-operative staging for members with biopsy-proven prostate cancer that is thought to be clinically localized after standard diagnostic evaluation, but who have a moderate to high probability of occult extra-prostatic metastasis. Second, post-prostatectomy or post-radiation staging when there is high suspicion of undetected residual prostate cancer or recurrence.

Both situations require documentation that the patient's clinical picture supports the moderate-to-high risk threshold. "We ordered it because the urologist wanted to rule things out" won't support medical necessity under this coverage policy. The chart needs to reflect the specific staging situation.

OctreoScan (HCPCS A9572 — Indium In-111 pentetreotide)

OctreoScan billing covers the diagnosis and staging of primary and metastatic neuroendocrine tumors with somatostatin receptors. The list of qualifying tumor types is long and specific. It includes carcinoid tumors, gastrinomas, glucagonomas, insulinomas, islet cell tumors of the pancreas, medullary thyroid carcinoma, paragangliomas, pheochromocytomas, pituitary adenomas, and VIPomas (Verner-Morrison syndrome).

Two less obvious inclications: carotid body tumors and tumor-induced osteomalacia (oncogenic osteomalacia) — but the osteomalacia indication covers diagnosis only, not staging or monitoring. Make sure your ICD-10 code supports the documented purpose of the scan.

Oncoscint (HCPCS A4642 — Indium In-111 satumomab pendetide)

Oncoscint immunoscintigraphy using satumomab pendetide is covered for three colorectal and ovarian cancer recurrence scenarios. First, as an alternative to second-look laparotomy when CEA is elevated but conventional imaging — including CT — shows no disease. Second, when a patient is about to undergo a potentially curative resection of an apparently isolated recurrence, and detection of additional occult lesions would change surgical planning. Third, for detection of occult recurrent ovarian cancer when rising tumor markers suggest recurrence but no other imaging or physical exam technique can locate the disease.

The real issue here is documentation. Each of these indications requires evidence that conventional imaging has already been performed and was insufficient. If you don't have CT results in the record before billing A4642, the claim will likely fail.

CEA-Scan (HCPCS A9568 — Tc-99m arcitumomab)

CEA-Scan using Tc-99m-arcitumomab is covered for detection of recurrent or metastatic colorectal cancer in the liver, extra-hepatic abdomen, and pelvis. This must be used in conjunction with CT scans — not as a standalone study. Bill CPT 78800, 78801, 78802, or 78803 depending on the scan area and modality.

Tc-99m-Sestamibi Scintigraphy (HCPCS A9500)

Technetium-99m-sestamibi (Tc-MIBI) scintigraphy covers four indications: assessment of malignant bone and soft tissue tumor response to therapy, detection of malignant axillary adenopathy from breast cancer, evaluation of metastatic thyroid cancer, and evaluation of parathyroid adenoma.

The parathyroid adenoma indication includes a specific note. A technetium Tc-99m pertechnetate (thallium) subtraction scan using HCPCS A9512 with the sestamibi scan is also considered medically necessary. Bill A9512 alongside A9500 when performing the subtraction technique — don't bundle them into one line and hope for the best.

Iobenguane Imaging (HCPCS A9508 and A9582)

HCPCS A9508 (Iodine I-131 iobenguane sulfate, diagnostic, per 0.5 millicurie) and A9582 (Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 millicuries) are covered under this policy when selection criteria are met. These agents are used in imaging for neuroendocrine tumors, including pheochromocytoma.

Prior authorization requirements for these studies under Aetna commercial plans should be verified before scheduling. Prior auth requirements can vary by plan type even within a single payer's book of business.

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Aetna Tumor Scintigraphy Exclusions and Non-Covered Indications

Several radiopharmaceutical therapy codes are explicitly not covered for the indications listed in CPB 0168.

CPT 79005 (radiopharmaceutical therapy, oral administration), 79101 (intravenous administration), 79300 (interstitial radioactive colloid), 79403 (radiolabeled monoclonal antibody, IV infusion), and 79445 (intra-arterial particulate administration) are all listed as not covered under this policy.

HCPCS A9509 and A9516 (Iodine I-123 sodium iodide, diagnostic) are also not covered for these indications. Scintimammography billed under HCPCS S8080 is excluded as well. S8080 is a plan-exclusion code in most commercial Aetna products — don't submit it expecting reimbursement under CPB 0168.

The distinction matters: this policy covers diagnostic tumor imaging, not radiopharmaceutical therapy. If your team conflates the two on a charge sheet, you will generate denials and potentially compliance exposure.

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Coverage Indications at a Glance

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Aetna Tumor Scintigraphy Billing Guidelines and Action Items 2025

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Tumor Scintigraphy Under CPB 0168

Covered CPT Codes (When Selection Criteria Are Met)

Other CPT Codes Related to CPB 0168

Code	Type	Description Copy
78830	CPT	Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s); SPECT
78831	CPT	Tomographic (SPECT), minimum 2 areas (e.g., pelvis and knees, abdomen and pelvis), single day imaging
78832	CPT	Tomographic (SPECT) with concurrently acquired CT transmission scan for anatomical review

Not Covered / Experimental CPT Codes

Covered HCPCS Codes (When Selection Criteria Are Met)

Not Covered HCPCS Codes

Code	Type	Description	Reason Copy
A9509	HCPCS	Iodine I-123 sodium iodide, diagnostic, per millicurie	Not covered for indications listed in CPB 0168
A9516	HCPCS	Iodine I-123 sodium iodide, diagnostic, per 100 microcuries, up to 999 microcuries	Not covered for indications listed in CPB 0168
S8080	HCPCS	Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including supply of radiopharmaceutical	Not covered for indications listed in CPB 0168

Key ICD-10-CM Diagnosis Codes

The full policy references 982 ICD-10-CM codes. Access the complete code list at app.payerpolicy.org/p/aetna/0168.

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