Description:
Radiopharmaceutical agents are isotopes, frequently attached to carrier molecules, used as adjuncts to nuclear medicine diagnostic or therapeutic procedures. Reimbursement for these agents is based on the cost of the radiopharmaceutical only. This is the case whether they are obtained as a unit dose or from kit preparation.

Policy:
The following radiopharmaceuticals will be considered medically necessary when used with the following procedures:

1. Pet scan radiopharmaceuticals
   The payment for the radio-tracer or radiopharmaceuticals is included in the allowance of the PET procedure. There is no separate reimbursement for the agents of the PET scans.

In vivo diagnostic aids are included in the radiological or medical diagnostic procedure performed, with these exceptions:

1. Medically necessary non-ionic contrast dyes
2. Perflutren Lipid Microsphere for patients with suboptimal echocardiograms to opacify the left ventricular chamber and to improve the delineation of the left ventrical endocardial border

The Nuclear Regulatory Commission (NRC) has strict procedures and guidelines. Persons administering radiopharmaceuticals should either have a license from the NRC or be credentialed by an institution having a broad license from the NRC.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2024 Forward     

01012024  NEW POLICY 

05/17/2024 Annual review, no change to policy intent.