Affordable Care Act Mandates Insurance Coverage of Annual CT Lung Screening for High-Risk Patients

In 2015, Moulton, Newsletter, Volume 7 Issue 1 by Jennifer

Medicare  Patients  Already Benefiting

A low-dose computed tomography (CT) screening test that has been shown to significantly reduce deaths from the nation’s leading cancer killer, lung cancer, has become more affordable for high-risk patients.

Effective Jan. 1, Medicare and most private insurance plans were mandated to cover the imaging test for high-risk patients under provisions of the Affordable Care Act. The Centers for Medicare and Medicaid Services in February announced its criteria for covering high- risk Medicare patients, effective immediately, said Stacy Moulton, MD, director of cross- sectional and body imaging for Radiologic Associates of Fredericksburg (RAF).

In anticipation of Medicare requirements for screening facilities, Medical Imaging of Fredericksburg became accredited as a Lung Cancer Screening Center by the American College of Radiology earlier this year. The outpatient imaging center, a partnership between RAF and Mary  Washington Healthcare, has provided CT lung screening since 2011, but most patients have paid the $366 cost out of pocket.

“Medicare’s decision to cover annual low-dose lung cancer screening without cost sharing is tremendous for this high risk population,” Dr. Moulton said. “Lung cancer is the number one cancer killer in the country, resulting in more deaths than breast, colon and prostate cancer combined. Low-dose CT lung cancer screening will provide this group of high risk individuals with an opportunity to identify cancers at an earlier and, thus, more treatable stage, with hopes of ultimately improving patient survival.”

He added that the National Lung Screening Trial results (published in the New England Journal of Medicine August 4, 2011) showed a 20% reduction in deaths for high-risk patients who received CT screening versus chest X-rays.

It was that study that prompted the U.S. Preventive Services Task Force (USPSTF) to give a “B” recommendation in favor of low-dose CT screening for high-risk patients. With the exception of “grandfathered” insurance plans, the Affordable Care Act mandates that insurers cover preventive measures with an “A” or “B” recommendation.

Who is “High Risk?”

To qualify for insurance coverage, patients must meet the criteria for being “high risk.” The USPSTF defined qualified high-risk patients as individuals who:

  • Are between the ages of 55 and 80
  • Have no signs or symptoms of lung disease
  • Have a 30-pack-year smoking history (for example, smoked an average pack a day for 30 years, or two packs a day for 15 years)
  • Are currently smoking or quit within the last 15 years

However, Medicare’s definition and requirements for an annual low-dose CT lung screening are more restrictive, defining qualified high-risk patients as individuals who:

  • Are between the ages of 55 and 77
  • Have no signs or symptoms of lung disease
  • Have a 30-pack-year smoking history (for example, smoked an average pack a day for 30 years, or two packs a day for 15 years)
  • Are currently smoking or quit within the last 15 years
  • Have seen a qualified physician, physician assistant, nurse practitioner, or nurse specialist for a consultation and written order

Medicare in February also confirmed requirements for radiologists and imaging facilities providing low-dose CT lung screening, including participation in an approved data registry, Dr. Moulton added.

For patients who are not seeking coverage through Medicare or private insurance, and are paying the full cost out of pocket, a physician order is not required. Age and smoking history criteria also may be more flexible depending upon a patient’s case, Brooks-Ford, CT screening coordinator for Medical Imaging of Fredericksburg.

Educating Patients about  Findings

One important point to stress when educating patients about low-dose CT lung screening is the prevalence of harmless “benign” nodules. “Per the National Lung Screening Trial results, an estimated 24% of high risk individuals will have a nodule detected during the screening, but approximately 96% of detected nodules will ultimately be benign,” Dr. Moulton explained.

For More Information

Referring physicians with questions about the CT lung screening test can contact Dr. Moulton through RAF’s Concierge Service at 855-RAF-LINE (855-723-5463) or concierge@rafadmin.com.

Patients with questions about the CT lung screening test can contact Carla Brooks-Ford at Medical Imaging of Fredericksburg, 540-741-7644 or toll free 866-828-7226

 

Pictured above: A patient is prepared for a CT scan at Medical Imaging of Fredericksburg. The CT unit is used for a range of tests including lung screenings.