Medicare No Longer Covering Lung Cancer Screening

For individuals with a high-risk of lung cancer, Medicare will no longer be covering annual low-dose Computed Tomography (CT) screenings.[i] The Centers for Medicare and Medicaid national coverage determination panel found there was not enough evidence for benefits over harms to be covered.[ii] The panel voted a mean 2.2 on a 5.0-point scale, showing low confidence in the benefits.[iii] The key concerns were the high false-positive rate of CT screening, indication creep outside of intended screening population, inability to assure low radiation doses for quality scans, and consistent interpretation and diagnostic workup in routine practice.[iv]

This decision comes despite a recent recommendation from the U.S. Preventative Services Task Force (USPSTF).[v] The American Academy of Family Physicians (AAFP) supports the denial of coverage due to insufficient evidence.[vi] The AAFP focused on the increased exposure to radiation with repeat screening.[vii] A current smoker in the affected group could get possibly 25 CT scans during his or her lifetime for screening alone.[viii] The AAFP suggested the USPSTF consider better risk/benefit patient profiling to minimize the amount of CT scans.[ix]

One main concern cited was the “generalizability” of the National Lung Screening Trial this recommendation was based on.[x] Generalizability refers to how well a study can be said to be representative of everyone. Only a quarter of the population of the study was 65 or older and no one enrolled was over the age of 74.[xi] Lung cancer disproportionately affects older adults, and the harms seem greater among populations with greater numbers of older adults.[xii] Analysis of the 65 and older group within the study showed a lower, insignificant reduction in lung cancer mortality.[xiii]

The other main concern was the 96% false positive rate among the 27% of positive scans.[xiv] New criteria may be able to bring that rate down to one in ten, however the panel was unconvinced without any actual evidence of this.[xv] Along this same line, there was a great deal of variability for the false-positive rates within radiologists.[xvi]While some radiologists only had 10%, the higher end was 50% or more, even with expert radiologists in the trial.[xvii] According to panelist Jo Carol Hiatt, MD, MBA, of Kaiser Permanente, this high level of variation in a relatively controlled environment raises serious concerns as it rolls out in the community .[xviii]

Further, the panel was worried about the inappropriate use of this technology.[xix]Allan M. Fendrick, MD, of the University of Michigan School of Public Health in Ann Arbor, claimed CMS is still spending a billion dollars screening 80-year-olds for colon cancer despite the lack of evidence for benefit.[xx] Some would like to see the standards taken away from professional societies, pointing to evidence of lower standards for acceptance.[xxi]

 If CMS were to cover these screenings, there would be a cost increase of $9.3 billion.[xxii] This cost is based on there being more lung cancer diagnoses, a shift towards an earlier stage of diagnosis, and increased expenditure.[xxiii] These numbers are based only on the next five years.[xxiv] During this time, approximately $5.6 billion more would be spent on the CT imaging alone.[xxv] These cost increases would mean an increase of $3.00 per month for the premiums of all Medicare members.[xxvi]However, there is evidence that lung cancers diagnosed at a distant stage would decrease from 57% to 40%.[xxvii]

This change does not affect private health insurance plans.[xxviii] This is due to the USPSTF recommendation for coverage.[xxix] Because of this, in accordance with the Patient Protection and Affordable Care Act, the marketplace and many other private plans are required to cover the screening with no out-of-pocket obligation to plan members.[xxx] There may be a cost share requirement, but this depends on the individual plan.[xxxi] Some groups have begun the process of petitioned CMS to begin covering CT lung cancer screening, despite the lack of evidence.[xxxii]



[i] Crystal Phend, Medicare Advisers Say No to Lung Cancer Screening, MedPage Today, http://www.medpagetoday.com/Pulmonology/LungCancer/45512 (last updated April 30, 2014).

[ii] Id.

[iii] Id.

[iv] Id.

[v] Chris Crawford, Medicare Panel Recommends Against Covering CT Screening for Lung Cancer, American Academy of Family Physicians (May 21, 2014), http://www.aafp.org/news/health-of-the-public/20140521medcacctrec.html.

[vi] Id.

[vii] Id.

[viii] Id.

[ix] Id.

[x] Crystal Phend, supra.

[xi] Id.

[xii] Id.

[xiii] Id.

[xiv] Id.

[xv] Id.

[xvi] Id.

[xvii] Id.

[xviii] Id.

[xix] Id.

[xx] Id.

[xxi] Id.

[xxii] Roxanne Nelson, CT Lung Cancer Screening Would Cost Medicare $9 Billion, Medscape (May 15, 2014), http://www.medscape.com/viewarticle/825235.

[xxiii] Id.

[xxiv] Id.

[xxv] Id.

[xxvi] Id.

[xxvii] Id.

[xxviii] Is Lung Cancer Screening Covered by Insurance? Lung Cancer Alliance, http://www.lungcanceralliance.org/get-information/am-i-at-risk/what-do-i-need-to-know-about-screening/insurance-coverage-for-lung-cancer-screening.html (last visited Aug. 1, 2014).

[xxix] Crawford, supra

[xxx] Id.

[xxxi] Is Lung Cancer Screening Covered by Insurance?, supra.

[xxxii] Id.