Amyloid PET/CT Ordering Instructions

Adler Imaging has been performing amyloid imaging with PET/CT since 2007, usually as part of research investigations. Now with the approval of Leqembi, we are performing clinically indicated PET/CT scans to confirm the presence of Beta-Amyloid (AB) pathology mandated by the FDA and required for entrance into the Monoclonal Antibodies Directed Against Amyloid for the Treatment of AD CED Study (often referred to as the Leqembi Registry).

We are working with patients who are referred to us to determine their insurance benefits and the coverage their plan allows. For patients with coverage who meet the requirements listed below, we can schedule immediately or once pre-auth is obtained. For patients with questionable coverage who are willing to pay for the radiopharmaceutical and a reduced fee for the scan prior to their appointment, we can schedule them immediately (and refund appropriately when 3rd party payment is received). Otherwise, we will schedule them as soon as their coverage is adequate.

Information for Clinicians:

1. Office visit note- Should contain a statement to the effect of "To determine if amyloid is present to qualify the patient for entry into an anti-amyloid registry.

2. Request/Order: Should be written for the procedure code 78814, along with one of the 5 codes below:

G30.0 Alzheimer’s disease w/early onset

G30.1 Alzheimer’s disease w/late onset

G30.8 Other Alzheimer’s disease

G30.9 Alzheimer’s disease, unspecified

G31.84 mild cognitive impairment, so stated

3. Clinical record- should indicate that patient has either MCI or mild dementia.

Information for Staff:

1. Please fax the following documents to 215-935-0023

a. Office note

b. Script

c. Demographics

d. Copies of all insurance cards

e. Neuropsychological testing results

f. Prior Brain imaging studies (MR, CT, PET)

i. Adler Imaging will request that prior MR or PET images be transmitted electronically

g. If we should contact anyone other than the patient directly, (e.g. patient, spouse, child, or caretaker of the patient), please write a note indicating who we should contact, along with their phone number on the fax cover sheet.

Thank you for your patience and support as we navigate through these exciting times together in the fight against Alzheimer’s disease.