All PlansCoverageMedium impact
Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease
Blue Cross & Blue Shield of Mississippi·MS · Neurology, Geriatrics, Nuclear Medicine +2 more·Medical Policy
We identified it
Jul 2, 2026
Summary
This policy establishes coverage and clinical guidance for PET imaging technologies used to evaluate Alzheimer disease, including FDA-approved amyloid beta tracers (florbetapir, florbetaben, flutemetamol), tau imaging (flortaucipir), and FDG-PET. The policy clarifies that these imaging modalities are adjuncts to clinical diagnosis and identifies patients for amyloid-targeting therapies (lecanemab, donanemab). Billing teams must understand coverage criteria, appropriate patient populations (mild cognitive impairment/mild dementia), and that amyloid pathology confirmation is required before initiating these therapies.
Action Required
REQUIREMENTS:
- Immediately: Billing and clinical teams should review this policy to understand coverage criteria for PET imaging in Alzheimer disease evaluation. This is a new policy (1 day old) from BCBS Mississippi.
- Before submitting claims: Verify that orders for amyloid PET imaging (florbetapir, florbetaben, flutemetamol) and tau PET imaging (flortaucipir) include appropriate clinical documentation confirming the patient has cognitive impairment and is being evaluated for AD or other cognitive decline.
- Before authorizing treatment: Ensure that lecanemab or donanemab therapy is only initiated AFTER amyloid beta pathology has been confirmed via PET imaging, as required by FDA labeling and this policy.
- Billing team: Add clinical notes to claims emphasizing that PET imaging is used as an adjunct to clinical diagnosis and for identifying candidates for amyloid-targeting therapy. Document that the imaging distinguishes AD from other dementias (especially for FDG-PET in atypical presentations).
- Credentialing/Prior Auth teams: Prepare for potential prior authorization requests for these PET studies. The policy does not establish specific prior auth requirements but clarifies medical necessity.
- CONSEQUENCE: Claims submitted without appropriate clinical documentation or for patients outside the specified indications may be denied. Claims for therapy initiation without documented amyloid pathology confirmation will be denied.