Coverage is Expanded for Lung Cancer Screening Using LDCT

Coverage is Expanded for Lung Cancer Screening Using LDCT The Centers for Medicare and Medicaid Services (CMS) has announced a shift in its eligibility criteria for coverage of lung cancer screening using low-dose CT (LDCT), thus joining other payers in adopting recommendations made by the US Preventive Services Task Force (USPSTF). In addition, CMS made other modifications to its eligibility criteria that will increase the ability of more people to obtain access to screening, effective February 10, 2022 with the posting of its Decision Memo.

Here is a review of the Medicare coverage criteria:

Previous Policy	Revised Policy
Coverage between age 55 and 77 years	Coverage between age 50 and 77 years
Smoking history of 30 pack years	Smoking history of 20 pack years
No signs or symptoms of lung cancer	No signs or symptoms of lung cancer
Current smoker or quit within 15 years	Current smoker or quit within 15 years
Screening follows a counseling and shared decision-making visit	Screening follows a counseling and shared decision-making visit
Written order from a physician for screening	Order from a physician for screening
Reading radiologist must document participation in continuing education	Criterion removed
Facilities must participate in a data registry	Criterion removed
Facilities must make available smoking cessation interventions for current smokers	Criterion removed
Independent Diagnostic Testing Facilities (IDTF) were precluded from LDCT screening	IDTFs may provide screening
Criterion had been removed by CMS	Facilities must use a standardized lung nodule identification and reporting system

None of the procedure (CPT) or diagnosis (ICD) coding for lung cancer screening using LDCT has changed from our previous summary.

The American College of Radiology (ACR) has worked with CMS to make these revisions, and the ACR applauded the changes. However, the CMS revised policy stops short of embracing all its recommended changes. The ACR says that CMS “should consider the following steps moving forward:

Continue Medicare coverage for older current and former smokers past age 78
Continue coverage for beneficiaries who stopped smoking more than 15 years prior
Inform future screening improvements by reinstating registry participation requirements
Drop the requirement for a shared decision-making session prior to the first screening (a current barrier to care).”

As we reported in July, 2021, many commercial payers adopted the USPSTF guidelines ahead of Medicare, and some offer coverage through age 80 rather than 77. The current list of payers with expanded guidelines now includes:

GHI/Emblem
Humana
Aetna
United Healthcare
Oxford Health Plan
Healthfirst of NY
Amerigroup/Wellmed
Horizon BCBS of NJ
BCBS of Delaware
Horizon NJ Health

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Sandy Coffta is the Vice President of Client Services at Healthcare Administrative Partners.

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