Coverage Policy Manual
Policy #: 2014020
Category: PPACA Preventive
Initiated: January 2015
Last Review: August 2018
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: LUNG CANCER SCREENING

Description:
The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010. The preventive services component of the law became effective 23 September 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force.
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention. Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds. Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination. Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
 
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay) by Health Plans for appropriate preventive care services provided by an in-network provider. If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
 
 

Policy/
Coverage:
EFFECTIVE JANUARY 1, 2016
 
Annual screening for lung cancer with low-dose computed tomography (LDCT) is covered for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay) in adults who met ALL of the following criteria:
    • Aged 55 to 80; AND
    • Have a 30 pack-year smoking history; AND
    • Currently smoke or have quit within the past 15 years; AND
    • Do not have a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
 
The appropriate ICD-9 codes to report this service are V15.82, V76.0 and 305.1.
 
The appropriate ICD-10 codes to report this service are F17.200, F17.201, F17.210, F17.211, F17.220, F17.221, F17.290, F17.291, Z12.2, and Z87.891
 
As of October 01, 2016, the code used to report this procedure is HCPCS G0297. Prior to this, HCPCS S8032 was used to report this service. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’. The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
EFFECTIVE  PRIOR TO JANUARY 1, 2015
 
Annual screening for lung cancer with low-dose computed tomography (LDCT) is covered for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay) in adults who met ALL of the following criteria:
 
    • Aged 55 to 80; AND
    • Have a 30 pack-year smoking history; AND
    • Currently smoke or have quit within the past 15 years; AND
    • Do not have a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
 
 
The appropriate ICD-9 codes to report this service  are V15.82 and 305.1.
 
The code used to report this procedure is HCPCS S8032. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’. The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 

Rationale:
The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery (Grade B recommendation).
The USPSTF recommendations include the following information (USPSTF, 2014):
  • Lung cancer is the third most common cancer and the leading cause of cancer death in the United States. The most important risk factor for lung cancer is smoking, which results in approximately 85% of all U.S. lung cancer cases.  Although the prevalence of smoking has decreased, approximately 37% of U.S. adults are current or former smokers. The incidence of lung cancer increases with age and occurs most commonly in persons aged 55 years or older. Increasing age and cumulative exposure to tobacco smoke are the 2 most common risk factors for lung cancer.
  • Lung cancer has a poor prognosis, and nearly 90% of persons with lung cancer die of the disease. However, early-stage non–small cell lung cancer (NSCLC) has a better prognosis and can be treated with surgical resection.
  • Most lung cancer cases are NSCLC, and most screening programs focus on the detection and treatment of early-stage NSCLC. Although chest radiography and sputum cytologic evaluation have been used to screen for lung cancer, LDCT has greater sensitivity for detecting early-stage cancer.
  • Although lung cancer screening is not an alternative to smoking cessation, the USPSTF found adequate evidence that annual screening for lung cancer with LDCT in a defined population of high-risk persons can prevent a substantial number of lung cancer–related deaths. Direct evidence from a large, well-conducted, randomized, controlled trial (RCT) provides moderate certainty of the benefit of lung cancer screening with LDCT in this population. The magnitude of benefit to the person depends on that person's risk for lung cancer because those who are at highest risk are most likely to benefit. Screening cannot prevent most lung cancer–related deaths, and smoking cessation remains essential.
  • The harms associated with LDCT screening include false-negative and false-positive results, incidental findings, overdiagnosis, and radiation exposure. False-positive LDCT results occur in a substantial proportion of screened persons; 95% of all positive results do not lead to a diagnosis of cancer. In a high-quality screening program, further imaging can resolve most false-positive results; however, some patients may require invasive procedures.
  • The USPSTF found insufficient evidence on the harms associated with incidental findings. Overdiagnosis of lung cancer occurs, but its precise magnitude is uncertain. A modeling study performed for the USPSTF estimated that 10% to 12% of screen-detected cancer cases are overdiagnosed—that is, they would not have been detected in the patient's lifetime without screening. Radiation harms, including cancer resulting from cumulative exposure to radiation, vary depending on the age at the start of screening; the number of scans received; and the person's exposure to other sources of radiation, particularly other medical imaging.
  • The USPSTF concludes with moderate certainty that annual screening for lung cancer with LDCT is of moderate net benefit in asymptomatic persons who are at high risk for lung cancer based on age, total cumulative exposure to tobacco smoke, and years since quitting smoking. The moderate net benefit of screening depends on limiting screening to persons who are at high risk, the accuracy of image interpretation being similar to that found in the NLST (National Lung Screening Trial), and the resolution of most false-positive results without invasive procedures.
  • Low-dose computed tomography has shown high sensitivity and acceptable specificity for the detection of lung cancer in high-risk persons. Chest radiography and sputum cytologic evaluation have not shown adequate sensitivity or specificity as screening tests. Therefore, LDCT is currently the only recommended screening test for lung cancer.
 
 
 

CPT/HCPCS:
G0297Low dose CT scan (LDCT) for lung cancer screening

References: PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act.

Screening for Lung Cancer: Systematic Review to Update the U.S. Preventive Services Task Force Recommendation : Lung Cancer: Screening. U.S. Preventive Services Task Force. January 2014. http://www.uspreventiveservicestaskforce.org/Page/SupportingDoc/lung-cancer-screening/screening-for-lung-cancer-systematic-review-to--update-the-us-preventive-services-task-force--recommendation-


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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