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AetnaCommercial · Coverage · Medical Policy · Oncology, Nuclear Medicine, EndocrinologyMedium impact

Lutetium Lu 177 Dotatate (Lutathera) and Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto) (CPB 0929, reviewed 2026-07-17)

Effective date
Not stated in the notice
Identified
Aug 16, 2026

Summary

Aetna's policy covers lutetium Lu 177 dotatate (Lutathera) and lutetium Lu 177 vipivotide tetraxetan (Pluvicto) for commercial medical plans. Lutathera is medically necessary for four doses total for specified somatostatin receptor-positive neuroendocrine tumors, poorly controlled carcinoid syndrome, and pheochromocytoma/paraganglioma when the listed criteria are met, and Pluvicto is medically necessary for up to 6 total doses lifetime for PSMA-positive metastatic castration-resistant prostate cancer when all listed criteria are met. Aetna considers both drugs experimental, investigational, or unproven for all other indications, including Lutathera for medullary thyroid carcinoma and meningioma.

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What to do

Action · 6 steps
01Pluvicto precertification: precertification is required of all Aetna participating providers and members in applicable plan designs.
02Call (866) 752-7021 for commercial plans or fax (888) 267-3277, and use the Statement of Medical Necessity precertification forms on the Specialty Pharmacy Precertification page.
03Lutathera (HCPCS A9513): confirm the member meets the criteria for one of the listed indications before billing, including disease progression on octreotide LAR or lanreotide where the criteria require it, and the four-dose course of 7.4 GBq (200 mCi) every 8 weeks in the dosage section.
04Pluvicto (HCPCS A9607): confirm all initial criteria are met, including PSMA-positive disease, prior AR pathway inhibition, and bilateral orchiectomy or an LHRH agonist or antagonist, before billing up to 6 doses at 7.4 GBq every 6 weeks.
05Reauthorization of Pluvicto is medically necessary only when there is no evidence of unacceptable toxicity or disease progression on the current regimen.
06Lutathera for medullary thyroid carcinoma and meningioma is experimental, investigational, or unproven, and ICD-10 codes C73 and D32.0 through D32.9 are listed as not covered for the indications in the policy.

Codes mentioned

791018430754520545225453054535546908440284403A9513A9607J1930J1932J2353J2354C25.4C74.10D44.7E34.00E34.09C61C73D32.0D32.9

Original notice

Lutetium Lu 177 Dotatate (Lutathera) and Lutetium Lu 177 Vipivotide Tetraxetan (Pluvicto) (CPB 0929, reviewed 2026-07-17)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesOncologyNuclear MedicineEndocrinologyCode 79101Code 84307Code 54520Code 54522Code 54530Code 54535Code 54690Code 84402Code 84403Code A9513Code A9607Code J1930Code J1932Code J2353Code J2354Code C25.4Code C74.10Code D44.7Code E34.00Code E34.09Code C61Code C73Code D32.0Code D32.9

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