Lutetium Lu Dotatate (Lutathera) and Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto) — CPB 0929 | AETNA Coverage Update

Aetna modified CPB 0929 covering Lutathera and Pluvicto, effective November 22, 2025. Here's what billing teams need to know before submitting claims under HCPCS A9513 and A9607.

Aetna, a CVS Health company, updated its Lutetium Lu Dotatate (Lutathera) and Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto) coverage policy under CPB 0929 Aetna system. This update expands Lutathera's covered indications to include lung and thymus NETs, well-differentiated grade 3 NETs, carcinoid syndrome, and pheochromocytoma/paraganglioma — a meaningful broadening that changes how your team should approach prior authorization and claim documentation. The primary billing codes at stake are HCPCS A9513 (Lutathera) and A9607 (Pluvicto), with supporting administration codes 79101 and 96413–96417.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna
Policy	Lutetium Lu Dotatate (Lutathera) and Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto)
Policy Code	CPB 0929
Change Type	Modified
Effective Date	November 22, 2025
Impact Level	High
Specialties Affected	Oncology, Nuclear Medicine, Urology, Radiation Oncology, RCM teams billing neuroendocrine and prostate cancer treatments
Key Action	Update prior authorization workflows and clinical documentation to reflect expanded Lutathera indications and new SSTR-PET imaging requirements before submitting claims under A9513 or A9607

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Aetna Lutathera and Pluvicto Coverage Criteria and Medical Necessity Requirements 2025

The Aetna Lutathera and Pluvicto coverage policy under CPB 0929 is more granular than most. Get the clinical documentation wrong and you'll see a claim denial. Get it right, and you have solid coverage across a wider set of indications than before.

Lutathera (HCPCS A9513) — What Aetna Now Covers

Aetna covers four total doses of Lutathera for somatostatin receptor-positive NETs across several distinct tumor types. Each tumor site has its own medical necessity criteria. This isn't a one-size-fits-all policy.

GI tract NETs (carcinoid tumors) — ICD-10 codes C7A.0–C7A.8 and C7B.0–C7B.9 apply. Aetna covers Lutathera when the member has recurrent, locoregional advanced, or metastatic disease and meets one of two criteria: clinically significant tumor burden, or disease progression on octreotide LAR (J2353) or lanreotide (J1930, J1932).

Pancreatic NETs — Covered under C25.4. This is a stricter standard. The member must meet both criteria: symptomatic disease, clinically significant tumor burden, or progressive/metastatic disease and documented progression on octreotide LAR or lanreotide. You need both boxes checked. One isn't enough.

Lung and thymus NETs — This is an expanded indication. Aetna now covers Lutathera for lung and thymus carcinoid tumors under the C7A series when the member has recurrent or locoregionally unresectable disease with progression on octreotide LAR or lanreotide. For distant metastatic disease, the criteria branch further — Aetna requires progression on octreotide LAR or lanreotide plus at least one of: clinically significant tumor burden with low-grade (typical carcinoid) histology, evidence of disease progression, intermediate-grade (atypical carcinoid) histology, or symptomatic disease.

Well-differentiated grade 3 NETs with favorable biology — This is a new category. Aetna covers four doses for unresectable locally advanced or metastatic well-differentiated grade 3 NETs when the member has favorable biology markers — specifically a Ki-67 under 55%, slow-growing tumor, and positive SSTR-based PET imaging. The member also needs clinically significant tumor burden or evidence of disease progression. The PET imaging requirement is critical for prior authorization. If your documentation doesn't include SSTR-based PET results, expect a denial.

Carcinoid syndrome — Covered when all three criteria are met: somatostatin receptor-positive NET of the GI tract, lung, or thymus; progression on octreotide LAR or lanreotide; and concurrent use of Lutathera with either octreotide LAR or lanreotide for persistent flushing or diarrhea, or with telotristat (no specific HCPCS code assigned — see code table) for persistent diarrhea in combination with octreotide LAR or lanreotide. Document the combination therapy explicitly. Aetna is checking for it.

Pheochromocytoma/paraganglioma — Covered under C74.10 and D44.7 when the member has locally unresectable disease or distant metastases. The standard is simpler here — either criterion qualifies. Still requires somatostatin receptor-positive confirmation.

Pluvicto (HCPCS A9607) — Prostate Cancer Reimbursement

The policy summary was truncated for Pluvicto, but the key facts stand. Prior authorization is required. Pluvicto is used for metastatic castration-resistant prostate cancer (mCRPC) under C61. PSMA PET imaging with A9593 or A9594 is part of the diagnostic pathway. Orchiectomy codes (CPT 54520, 54522, 54530, 54535, 54690) and testosterone labs (84402, 84403) appear in the related-code set, reflecting the androgen deprivation therapy context for prostate cancer billing.

If you're billing Pluvicto under A9607, loop in your compliance officer before the effective date of November 22, 2025. The full criteria aren't published in the truncated summary, and submitting without complete documentation is how you get denials reversed into appeals that take six months to resolve.

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Aetna Lutathera and Pluvicto Exclusions and Non-Covered Indications

Aetna states plainly: Lutathera is experimental, investigational, or unproven for all indications not listed above. That's a broad exclusion. If you're billing A9513 for a tumor type not named in the criteria — meningioma, thyroid cancer, or any off-label use — Aetna won't cover it.

The ICD-10 data includes D32.0–D32.9 (meningioma) and C73 (thyroid), both present in the code set. Their inclusion as "related codes" doesn't mean covered. It means Aetna has seen those diagnoses paired with these drugs and is watching for them. Don't bill A9513 against D32.x or C73 expecting reimbursement — you won't get it.

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Coverage Indications at a Glance

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Aetna Lutathera and Pluvicto Billing Guidelines and Action Items 2025

This policy is live as of November 22, 2025. If your team hasn't updated workflows yet, start today.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Lutathera and Pluvicto Under CPB 0929

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
A9513	HCPCS	Lutetium Lu 177, dotatate, therapeutic, 1 millicurie
A9607	HCPCS	Lutetium Lu 177 vipivotide tetraxetan, therapeutic, 1 millicurie

Other CPT Codes Related to CPB 0929

Other HCPCS Codes Related to CPB 0929

Key ICD-10-CM Diagnosis Codes

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