SNMMI Seeks to Change Aetna's PET Coverage Policy

April 18, 2018

SNMMI recommends that Aetna reconsider and change its PET Coverage Policy for Dotatate and Fluciclovine. Aetna's March 30, 2018, update to its coverage policy is available here. It maintains its blanket non-coverage policy for both Dotatate and Fluciclovine. 

SNMMI's letter on Dotatate points out that the policy is inconsistent with FDA's June 16, 2016, approval of the radiopharmaceutical, updated guidelines from the National Comprehensive Cancer Network, and SNMMI's Appropriate Use Criteria (AUC) that involved representatives from 12 stakeholder groups. Moreover, a just released Aetna revision for SPECT continues to cover 111In-pentetreotide, a treatment which SNMMI's AUC reports to be inferior to Dotatate in several ways.

SNMMI's letter on Fluciclovine shows that Aetna's policy is inconsistent with recent advances. In May 2016, the US Food and Drug Administration (FDA) approved the use of this PET imaging agent in men with suspected prostate cancer recurrence based on elevated blood prostate specific antigen (PSA) levels following prior treatment. Recently, the National Comprehensive Cancer Network (NCCN) updated its guidelines to include fluciclovine imaging, stating that fluciclovine 18F PET/CT or PET/MRI should be considered in the clinical workup of patients with recurrence or progression of their prostate cancer. NCCN guidelines are the recognized standard for clinical policy in cancer care. 

We know that Aetna wants to be known for allowing its beneficiaries access to state-of-the-art care, and we believe the company will modify this coverage policy in that spirit.