In 2014, Congressional regulations mandated that insurance companies must pay for low dose CT screening for “at risk Medicare beneficiaries. A new procedure code (G0297) was established for the special CT scan of the chest without contrast but Congress did not require all insurance companies to accept that code. Now some third party payers request the use of G0297 while others continue to ask providers to use the traditional CT chest without contrast CPT code (71250). This is only one of the inconsistencies that mark lung cancer screening regulations.
Guideline criteria for Medicare patients (National Coverage Determination (NCD) for Lung Cancer Screening) differ somewhat from those criteria used by Medicaid and Commercial insurers (which were written by the US Preventive Services Task Force).
Notes: subtle differences between these two sets of Criteria exist and include the following:
1. Commercial/Medicaid screening age limit is 80, but for Medicare the upper age limit is 77.
2. Commercial/Medicaid screening is excluded for patients with severe health problems that may limit life expectancy or ability to have major curative lung surgery.
3. Medicare guidelines specifically exclude from screening patients with weight loss, hemoptysis, masses or lymphadenopathy which may suggest underlying lung cancer. Stable COPD, cough, and dyspnea are not considered exclusions from screening.
Counseling and Shared Decision making, required by Medicare, spells out in detail what must be discussed and documented in the medical record. For more information see:
Fortunately, RBMs usually do not enforce the Counseling and Shared Decision Making rule when approving lung cancer screening tests.
Lesson #33 Lung cancer screening for patients at high risk for developing lung cancer can be approved, as long as all criteria are met. These criteria detail the patients
• smoking history (past or present),
• age, and
• underlying health status and
• ability to have curative thoracic surgery.
Some RBM guidelines go into much greater detail and outline required counseling and shared decision making, even though these criteria may not be mandated for prior authorization. Becoming familiar with guidelines for screening and differences between commercial and Medicaid, or Medicare beneficiaries will avoid unnecessary denials and peer-to-peer calls.