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COVERAGE OF CT SCREENING FOR EARLY DETECTION OF LUNG CANCER
February 5, 2015 marked the day that nearly 10 million Americans, including those within the Medicare population have coverage for lung cancer screening. This means that Medicare beneficiaries between the ages of 55 and 77 with a 30 pack year history will be covered. Providers are immediately eligible for reimbursement as permanent codes and levels are finalized.
On Monday, November 10, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a draft decision requiring Medicare coverage of low-dose computed tomography (CT) lung cancer screening for at-risk beneficiaries. Approximately four million Medicare beneficiaries fit the eligibility criteria for screening. The decision is aligned with the recommendations submitted to CMS in September by a coalition led by LCA, the American College of Radiology (ACR) and The Society of Thoracic Surgeons that included nearly 100 other professional societies, public health organizations, medical centers and patient groups. The final decision will be issued in February of 2015.
On December 30, 2013, the U.S. Preventive Services Task Force (USPSTF) gave screening for those at high risk for lung cancer with low dose CT scans a “B” recommendation, its second highest approval rating. A high rating by USPSTF is a crucial initial step in making this screening an essential health benefit pursuant to the Affordable Care Act. It is also an important element in coverage decisions by private insurance, Medicare and Medicaid.
The USPSTF recommends CT screening for current and former smokers ages 55 to 80 with a history of smoking the equivalent of a pack a day for 30 years or two packs a day for 15 years. The recommendation includes those who have quit within the past 15 years.
In addition, Centers for Medicare and Medicaid Services (CMS), at the urging of Lung Cancer Alliance initiated the National Coverage Analysis of lung cancer screening in February 2014. CMS determines which preventive health services (screenings, vaccinations, etc.) will be covered by Medicare for eligible adults 65 and older, younger adults with disabilities and persons receiving dialysis for late stage kidney disease. Unlike most private health plans, CMS is not required to cover new preventive services that receive an A or B rating from the USPSTF. Instead, CMS bases its coverage decision on these USPSTF recommendations and evidence that a new preventive service is reasonable and appropriate for the Medicare population. This process could take up to a year.
No single health policy decision will have a greater immediate impact on lung cancer survival than full and equitable deployment of lung cancer screening for those at high risk. Tens of thousands of lives a year are literally at stake.
Screening those at known high risk now will accelerate research into risk factors tied to the increasing number of non-smoking related lung cancer, and into more effective diagnostic and treatment tools for all types of lung cancer. We recognize that there are other high risk categories that fall outside of this recommendation and will be working to optimize the recommendations and coverage, consistent with the guidelines released by the National Comprehensive Cancer Network.
To see the full coverage decision go to click here.