Imaging experts slam Humana for ‘ill-informed and wrong’ decision to deny coverage for PET/CT exams

Two nuclear medicine experts railed against Humana for its recent decision to refuse coverage for PET/CT exams, calling the move “nonsense” in an editorial published recently.

The critique comes two weeks after the American Society of Nuclear Cardiology said it “adamantly disagrees” with the insurance giant’s coverage determination; a sentiment echoed last week by the Society of Nuclear Medicine and Molecular Imaging.

Authors Johannes Czernin, MD, of UCLA’s School of Medicine, and Andrei Iagaru, MD, of Stanford University’s School of Medicine, both sharply questioned the anonymous authors of the “noncoverage” document, indicating they are either unaware of current imaging best practices or are willfully deceiving patients.

“The nonsense of all these decisions is blatantly apparent,” the pair argued on Nov. 13 in the Journal of Nuclear Medicine.

“It is also apparent that the anonymous authors had extremely limited insights into standard-of-care and state-of-the-art diagnostic imaging, cancer care, and care of cardiovascular patients,” Czernin and Iagaru added. “The alternative is that the document’s goal is to mislead the public in an attempt to block access to technology that is the standard of care in 2020.”

In its coverage statement, Humana concluded that several PET/CT imaging applications are investigational and experimental and therefore ineligible for coverage. Those include but are not limited to cardiac, gastric or esophageal, and neurologic indications. Total-body PET/CT exams for screening, including cancer, may also be denied.

The editorialists, however, point out that these indications have been covered by the Centers for Medicare and Medicaid Services for many years, based on exhaustive data demonstrating their positive impact on care. SNMMI and ASNC both have made similar arguments.

In their piece, the doctors noted Humana’s decision to disallow diagnostic CT coverage throughout most of the body regions now forces patients to complete two clinical visits to receive a PET/CT exam that could be completed in a single visit.

“Humana invokes the bizarre argument that a PET exam with diagnostic CT would expose patients to more radiation than is incurred from separately performed diagnostic CT and PET/nondiagnostic CT,” they noted. “In fact, the opposite is true.”

Additionally, both imaging providers said they were “puzzled” by the authors’ misconception about the cost of PET/CT imaging, which is minimal in cancer care and cardiovascular diseases. They noted it is likely that the “bureaucratic process” involved in developing the coverage documents and monitoring compliance will cost more than the tests themselves.

The pair called on others to get involved in overturning the coverage clauses.

“Until the anonymous authors provide solid arguments, we will be relentless in opposing such actions,” they wrote, adding that it’s their hope “patients and physicians will join the discussion, make their voices heard, and demand an immediate reversal of this ill-informed and wrong decision.”

Read more from the authors in the Journal of Nuclear Medicine here.