February 25, 2022 — The U.S. 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, the 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.
Below 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|
|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 (current procedural terminology, 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 the following:
- United Healthcare
- Oxford Health Plan
- Healthfirst of NY
- Horizon BCBS of NJ
- BCBS of Delaware
- Horizon NJ Health
Healthcare Administrative Partners will continue to follow changes to this policy going forward.