CommercialCoverageMedium impact
Tumor Scintigraphy (CPB 0168, reviewed 2026-03-27)
Aetna·Oncology, Nuclear Medicine, Radiology +1 more·Medical Policy
Effective date
Mar 27, 2026
We identified it
Aug 14, 2026
Summary
Aetna has consolidated and updated its tumor scintigraphy medical policy (CPB 0168), replacing three previous policies (CPBs 239, 309, 320). The policy clarifies coverage criteria for multiple imaging modalities including ProstaScint, Oncoscint, CEA-Scan, Tc-99m-sestamibi, OctreoScan, MIBG imaging, lymphoscintigraphy, and related procedures, with specific medical necessity requirements and extensive experimental/unproven designations. Billing teams must verify each imaging type meets the defined indications to ensure claim approval.
Action Required
By March 27, 2026: Billing and clinical teams must update prior authorization workflows and claim submission procedures for all tumor scintigraphy services. (1) Obtain or update the complete policy document with specific CPT and HCPCS codes referenced in the full policy text (codes were truncated in the provided excerpt). (2) For each imaging modality covered (ProstaScint, Oncoscint, CEA-Scan, Tc-99m-sestamibi, OctreoScan, MIBG imaging, lymphoscintigraphy, Lymphoseek, Azedra, AdreView), map the corresponding billing codes to their specific medical necessity criteria in the authorization system. (3) Configure billing software to flag claims for manual review or automatic denial if they do not match one of the defined covered indications. (4) Provide providers with updated clinical documentation requirements—especially for oncology and urology practices—to ensure medical necessity is clearly documented before imaging is ordered. (5) Communicate to radiology and oncology departments the experimental/investigational designations (e.g., Oncoscint for melanoma/breast cancer screening, OctreoScan for non-specified neuroendocrine conditions, MIBG for cardiac indications) so they do not order these off-label uses. Claims submitted for experimental indications will be denied. This policy supersedes CPBs 239, 309, and 320, so remove those from active use immediately.