Medicare Plans To Cover Lung Cancer Screening

By Crystal Phend, Senior Staff Writer, MedPage Today

Annual low-dose CT lung cancer screening for high-risk individuals will be covered by Medicare, albeit with restrictions, according to a preliminary decision from the agency.

The Centers for Medicare and Medicaid Services (CMS) said Monday that low-dose CT would be reimbursed once per yearfor beneficiaries who fit the criteria of the pivotal National Lung Screening Trial:

• Ages 55 to 74
• At least a 30 pack-year history of smoking
• A current smoker or one who quit in the prior 15 years

However, there were additional criteria as well.

For the initial screen, the beneficiary would need a written order obtained during a "lung cancer screening counseling and shared decision-making visit" from a physician, physician assistant, nurse practitioner, or clinical nurse specialist.

CMS also detailed elements for that visit, radiologist eligibility criteria, and imaging center eligibility criteria.

On subsequent screens, the written order could be from an annual wellness visit, tobacco cessation counseling session, or other visit.

The announcement is in contrast to the recommendations of the agency's advisory panel, which had voted a lack of confidence in sufficient evidence for benefit over harms, citing the high false-positive rate of CT screening, indication creep outside of the intended screening population, inability to assure quality scans with low radiation dose, and the lack of consistent interpretation and diagnostic workup in routine practice.

"CMS got it right," Lori Fenton-Ambrose, president and CEO of the Lung Cancer Alliance, told MedPage Today. "The time to move forward and educate those at risk, especially our seniors, is now."

She and others had warned against the two-tiered system that would be established had CMS not covered screening. Under the Affordable Care Act, private insurers will be required to cover the USPSTF-recommended screening -- including the low-dose CT lung cancer scans -- without cost-sharing beginning Jan. 1, 2015, but those on Medicare would have had to pay entirely out-of-pocket if CMS had denied coverage for the scan.

The American Thoracic Society and the American College of Chest Physicians also welcomed the decision.

"Low-dose CT has been shown to reduce mortality when used to screen individuals who are at high risk for developing lung cancer because of their age and smoking history," Charles Powell, MD, of Mount Sinai in New York and chair of the American Thoracic Society's thoracic oncology assembly, said in a statement.

"Thoughtful implementation of lung cancer screening with strict attention to monitoring of screening program adherence to standards for centers of excellence and with routine utilization of smoking cessation and multidisciplinary management will help to maximize the benefits and minimize the harms of screening," he added.

A 30-day comment period will be in place before the final determination.