Dec 072014

Ignoring its advisory panel, the Centers for Medicare and Medicaid Services (CMS) announced that annual low-dose CT lung cancer screening for high-risk individuals will be covered by Medicare. However, CMS applied restrictions that will limit access to screening, avoiding the chaotic marketplace free-for-all that would have resulted from an unrestricted approval.

Medicare will pay for one lung cancer screening CT per year for beneficiaries meeting the entry criteria of the National Lung Screening Trial (NLST): aged 55-74, with at least 30 pack-years of smoking now or previously, and not having quit in the prior 15 years.

In a nod to the complexity of the decision to screen or not, CMS requires the first lung cancer screening CT be ordered during what they call a "lung cancer screening counseling and shared decision-making visit" by a physician or associated midlevel provider. They seem to be requiring this be a dedicated visit, not squeezed into another appointment. Follow-up yearly screens could be done on any visit.

CMS also erected a second barrier, restricting the radiology centers who will be allowed to be paid for performing and interpreting lung cancer screening CTs.

Initially, only centers that were part of the original NLST or are accredited diagnostic imaging centers experienced with low-dose CT lung cancer screening will be allowed to participate. Radiology centers will also have to submit extensive data to a national registry on all screened Medicare beneficiaries, including health outcomes after screening, a significant administrative burden which will deter many centers from signing up.

The decision is a bit of a surprise. Medicare's advisory panel originally recommended against paying for lung cancer screening, even in the highest-risk patients, citing its unease that the benefits of lung cancer screening would be preserved when unleashed in the community, outside a controlled trial.

Meanwhile, the other side of the federal government's mouth (USPSTF + Affordable Care Act) continued to promote lung cancer screening as a universally recommended test for all patients meeting the NLST entry criteria. Since the ACA dictates that all private insurers will be expected to pay for USPSTF-recommended preventive care in full without a copayment requirement, this split threatened to create a two-tier system of care between patients insured by Medicare and those privately insured.

The preliminary decision is pending a 30-day period for comments by stakeholders.

It's unclear exactly when Medicare coverage will start, and how much physicians will be paid for providing lung cancer screening services (counseling, CT interpretation, etc). It's also unclear if subsequent scans after an initial abnormal scan will be covered by Medicare, and at what payment rate.

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

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Medicare bucks advisers, will pay for lung cancer screening