Private insurance will cover low-dose CT screening

Private insurance will cover low-dose CT screening

by Loren Bonner, DOTmed News Online Editor | January 09, 2014
Dr. Ella Kazerooni
Now that the U.S. Preventive Services Task Force has endorsed low-dose CT lung cancer screening for high-risk patients, what does it mean for Medicare and private insurance coverage?

Right before the New Year, the USPSTF officially signed off on its recommendation to screen heavy smokers for lung cancer using low-dose CT. Because the final statement was put into place before January 1, 2014, all private insurance payors will be required to cover the screening by January 2015.

"This is huge," Dr. Ella Kazerooni, chair of the American College of Radiology Thoracic Imaging Panel, told DOTmed News. "It is now incumbent upon the private payors under the Affordable Care Act to cover lung cancer screening as a required benefit within the next calendar year."

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In other words, by January 2015, all private insurance payors will be required to cover the screening because of this final grade B recommendation by the USPSTF.

Normally, a recommendation by the USPSTF is a win for Medicare coverage, which private insurance payors normally follow, but the jury is still out on whether Medicare will cover the same population for low-dose lung CT screening, put certain criteria around coverage, or require coverage with evidence development.

"CMS does not fall under the same rules and can make its own decision," said Kazerooni.

The Affordable Care Act distinguishes between private payors and Medicare, leaving CMS on its own.

Whatever the outcome, providers need to be ready. The ACR is expected to finalize CT lung cancer screening appropriateness criteria and corresponding practice guidelines and standards this spring.

Kazerooni said they are developing a lung image database and practice auditing system that is similar to the well-established BIRADS system used in mammography. This is appropriate for any national screening program with standard terms, techniques and a reporting structure.

Based largely on the results of the federally sponsored National Lung Screening Trial, the USPSTF released a draft this summer of the recommendation in favor of annual CT screenings for adults aged 55-80 years who have a 30 pack/year smoking history — meaning one pack a day for 30 years or the number of packs of cigarettes smoked per day by the number of years the person has smoked.

The National Lung Screening Trial (NLST) showed for the first time that CT lung screening can save lives when performed in the context of careful patient selection and follow-up. CT as a screening tool has normally been controversial, and still is seen that way by many due to concerns about radiation exposure, the costs of imaging, and follow-up testing on patients.

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