Aetna gives PET payment go-ahead

Aetna Health Plans has joined the growing list of private insurancecompanies that have authorized reimbursement of positron emissiontomography scans.

Aetna began covering PET scans early this year after the company'stechnology review board last winter recommended use of the modalityfor three applications, according to William McGivney, head oftechnology assessment for the insurer.

Blue Cross/Blue Shield (BC/BS) issued a similar endorsementof PET in July (SCAN 8/12/92). PET supporters hope that privatethird-party reimbursement will snowball as a federal decisionapproaches on Medicare reimbursement for PET.

Aetna's authorization includes two neurological applicationsrecommended by BC/BS, but it also covers cardiac PET, which wasnot recommended by BC/BS. This will help overcome the perceptionthat cardiac PET is still an experimental procedure, accordingto Michael McGehee of the Institute for Clinical PET in Washington,DC.

"The importance to us is the cardiac component of it,"McGehee said. "That firmly establishes that a national firmis going to be paying for cardiac scans. That's a significantperceptual point."

Aetna reimburses PET as follows:

• for presurgical evaluation of patients with temporallobe seizures that are not controlled by epilepsy medication;

• for evaluation of primary brain tumors, to provideprognostic information, to identify the appropriate site for biopsyand to distinguish recurrent tumor from necrosis after radiationor chemotherapy; and

• for presurgery evaluation to determine myocardial viabilityin patients being considered for coronary revascularization.

Aetna's decision is also important because it applies to allhealth plan policyholders. The national BC/BS endorsement wasnot binding on individual BC/BS affiliates, although most affiliatesabide by the national office's recommendations.

McGehee expects the Health Care Financing Administration tomake a decision on Medicare PET reimbursement toward the middleof next year. If PET gets the green light, a decision on reimbursementrates will also be made at that time. The ICP has been gatheringinformation on scan charges at PET sites across the country andwill present the data to HCFA to help the agency draw up a reimbursementschedule, McGehee said.