Medicare will pay for lung cancer screening chest CT -- now up to age 77

Medicare will pay for annual low-dose chest CT for lung cancer screening, for former and current heavy smokers between the ages of 55 and 77. The Centers for Medicare and Medicaid Services (CMS) announced the decision last week. CMS had previously signaled they would set the upper age limit at 74, the same as in the National Lung Screening Trial (NLST) that demonstrated lung cancer screening's benefit (but lower than the 80 years recommended by USPSTF). As with most decisions it makes, it is likely that CMS responded to pressure brought by advocacy groups, lobbying interests and patients who would be affected. CMS had originally been advised not to cover lung cancer screening at all: its panel believed the benefits seen in the tightly controlled NLST could easily be lost during a chaotic, nationwide rollout of screening in the community. However, that would have set up an inconsistent two-tier system, as well as public outcry, since the Affordable Care Act requires private insurers to pay for lung cancer screening (after the USPSTF included it its panel of recommended screening tests). People with a 30 pack-year smoking history, still smoking or who have not quit more than 15 years are eligible for lung cancer screening paid by Medicare. A doctor must write the order for the first screening test, stating that the patient received counseling on lung cancer screening which included a "shared decision making process" (whatever that is). Each annual screening would require a similar order. The counseling visit may be performed by a midlevel provider; it's unclear from CMS's statement whether separate, dedicated counseling visits must be performed (vs. adding a "counseling" code to an ordinary office visit). To be eligible for Medicare payments for lung cancer screening, radiology centers must:

• Have participated in the NLST or have an accreditation as an advanced diagnostic imaging center with training and experience in LDCT lung cancer screening,

• Use low dose chest CTs with an effective radiation dose less than 1.5 mSv, and

• Collect data on every chest CT performed (CT dose, patient's smoking history, whether symptoms are present, etc.) and submit it to a national registry approved by CMS. This is still being defined.

Radiologists must be board certified, have interpreted at least 300 chest CTs in the past 3 years, and be up to date on CME. The American College of Radiology (ACR) is offering a Lung Cancer Screening Center Designation meeting CMS's requirements and advertising rapid turnaround (for centers already accredited in general CT scanning). ACR is lobbying CMS to continue to pay for lung cancer screening chest CT with CPT® code 71250 (CT thorax without contrast material); Medicare pays around $126-178 for this code currently. No one knows what lung cancer screening's eventual cost will be; it's been estimated at about $2 billion per year, about $81,000 per quality-adjusted life year saved, and about $3 per month in additional Medicare premiums per beneficiary.

"Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439N)": Centers for Medicare and Medicaid Services website.