CT Screening for Lung Cancer in Heavy Smokers - Body
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CT Screening for Lung Cancer in Heavy Smokers
Policy Number: PG0049 ADVANTAGE | ELITE | HMO
Last Review: 04/01/2021 INDIVIDUAL MARKETPLACE |
PROMEDICA MEDICARE
PLAN | PPO
GUIDELINES
This policy does not certify benefits or authorization of benefits, which is designated by each individual
policyholder terms, conditions, exclusions and limitations contract. It does not constitute a contract or
guarantee regarding coverage or reimbursement/payment. Self-Insured group specific policy will
supersede this general policy when group supplementary plan document or individual plan decision
directs otherwise.
Paramount applies coding edits to all medical claims through coding logic software to evaluate the
accuracy and adherence to accepted national standards.
This medical policy is solely for guiding medical necessity and explaining correct procedure reporting
used to assist in making coverage decisions and administering benefits.
SCOPE
X Professional
X Facility
DESCRIPTION
In the United States, lung cancer is the most commonly occurring noncutaneous cancer in men and a woman
combined, and is the leading cause of cancer deaths. The most important risk factor for lung cancer is tobacco use.
Other risk factors are small compared with cigarette smoking—these causal factors include exposures to
environmental and occupational substances and family history of lung cancer. Currently, most lung cancer is
diagnosed clinically when patients present with symptoms such as persistent cough, pain and weight loss;
unfortunately, patients with these symptoms usually have advanced lung cancer. Due to the prevalence and the
mortality associated with lung cancer, detecting the disease and initiating treatment at an early stage, in particular,
for at-risk individuals is important for improving survival. Chest x-ray (CXR) and sputum cytology have been the
most common methods used for screening for lung cancer.
More recently, low-dose computed tomography (LDCT) has been proposed as a method of screening
asymptomatic, high-risk individuals for lung cancer. The goal of screening is to detect disease at a stage when it is
not causing symptoms and when treatment will be most successful. It has been suggested that spiral CT may be
an improved early lung cancer detection tool based on the greater sensitivity for detecting early-stage cancer it
appears to have over CXR and sputum cytology to detect lung cancer at an earlier stage. However, questions
remain as to whether screening with spiral CT can reduce lung cancer mortality. This is the subject of ongoing
randomized controlled clinical trials. Potential disadvantages associated with this test include false-positive results
and over-diagnosis.
The United States Preventive Services Task Force (USPSTF) recommends annual screening for lung cancer with
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.
POLICY
PG0049 – 04/01/2021 Low dose CT scan (LDCT) for lung cancer screening in heavy smokers (71271 effective
1/1/2021/G0297 deleted 12/31/2020) does not require prior authorization for HMO, PPO,
Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage
Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT
scan (G0296) does not require prior authorization for HMO, PPO, Individual Marketplace,
Elite/ProMedica Medicare Plan, Advantage
When the services are provided as Preventive Services procedures (G0296, G0297, 71271)
must be billed with the medically indicated/supported screening ICD-10 diagnosis codes
F17.210, F17.211, F17.213, F17.218, F17.219, Z87.891 (nicotine dependence)
COVERAGE CRITERIA
HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage
The use of low-dose, non-contrast spiral (helical) multi-detector CT imaging as a screening technique for lung
cancer is considered medically necessary when used to screen for lung cancer for certain high-risk individuals
when ALL of the following criteria are met:
1. Individual has no signs or symptoms suggestive of underlying lung cancer which includes, but is not limited
to the following: unexplained cough, hemoptysis, or unexplained weight loss of more than 15 pounds in the
past year
2. Individual has NO health problems that substantially limit life expectancy or the ability or willingness to have
curative lung surgery
a. Congestive heart failure
b. Advanced cancer from another site
c. COPD with the use of oxygen
3. Individual is between 55-80 (effective 3/09/2021) 50-80 years of age
4. There is at least a 30 (effective 3/09/2021) 20 pack-year smoking history and currently smoking
5. If the individual is a former smoker, that individual had quit smoking within the previous 15 years
6. Screening will occur no more often than annually
These services (G0296, G0297, 71271) must be billed with the medically indicated/supported screening ICD-10
diagnosis codes F17.210, F17.211, F17.213, F17.218, F17.219, Z87.891 (nicotine dependence).
The use of CT scanning as a screening technique for lung cancer in asymptomatic individuals is considered
investigational and therefore not medically necessary. Low dose CT scan (LDCT) for lung cancer screening is non-
covered when the above criteria are not met and for all other indications.
Paramount considers LDCT experimental and investigational as a screening test for all other indications (e.g.,
asbestos-exposed individuals).
Paramount considers computer-aided detection for chest radiographs experimental and investigational for
screening or diagnosis of lung cancer and for all other indications. There is presently inadequate evidence in the
medical literature that population-based mass lung cancer screening with computer-aided detection for chest
radiographs will contribute substantially to the detection of smaller cancers, or decreases mortality.
Lung cancer screening for asymptomatic individuals is non-covered utilizing the following tests for any indication:
Chest x-ray
EarlyCDT-Lung test
PAULAs test
PET scan
Sputum cytology
These tests are considered experimental and investigational for lung cancer screening because their effectiveness
for this indication has not been established.
PG0049 – 04/01/2021Counseling and Shared Decision-Making Visit
Before the first lung cancer LDCT screening occurs, the member must receive a written order for LDCT lung cancer
screening during a lung cancer screening counseling and shared decision-making visit that includes the following
elements and is appropriately documented in the beneficiary’s medical records:
Must be furnished by a physician or qualified non-physician practitioner (meaning a Physician Assistant
(PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS); and
Must include all of the following elements:
o Determination of member eligibility including age, absence of signs or symptoms of lung cancer, a
specific calculation of cigarette smoking pack-years; and if a former smoker, the number of years since
quitting
o Shared decision-making, including the use of one or more decision aids, to include benefits and harms
of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation
exposure
o Counseling on the importance of adherence to annual lung cancer LDCT screening, impact of co-
morbidities, and ability or willingness to undergo diagnosis and treatment
o Counseling on the importance of maintaining cigarette smoking abstinence if former smoker; or the
importance of smoking cessation if current smoker and, if appropriate, furnishing of information about
tobacco cessation interventions
o If appropriate, the furnishing of a written order for lung cancer screening with LDCT
Written orders for subsequent annual LDCT screens may be furnished during any appropriate visit with a physician
or qualified non-physician practitioner (PA, NP, or CNS).
The U.S. Preventive Services Task Force (USPSTF) recommends annual screening for lung cancer with low-dose
computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 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.
CODING/BILLING INFORMATION
The inclusion or exclusion of a code in this section does not necessarily indicate coverage. Codes referenced in
this clinical policy are for informational purposes only.
Codes that are covered may have selection criteria that must be met.
Payment for supplies may be included in payment for other services rendered.
CPT CODES
71271 Computed tomography, thorax, low dose for lung cancer screening, without contrast materials(s)
HCPCS CODES
G0296 Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan
(service is for eligibility determination and shared decision making)
G0297 Low dose CT scan (LDCT) for lung cancer screening Deleted 12/31/2020
ICD-10-CM CODES REQUIRED FOR COVERAGE
F17.210 Nicotine dependence, cigarettes, uncomplicated
F17.211 Nicotine dependence, cigarette, in remission
F17.213 Nicotine dependence, cigarettes, with withdrawal
F17.218 Nicotine dependence, cigarettes, with other nicotine-induced disorders
F17.219 Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders
Z87.891 Personal history of nicotine dependence
Paramount reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to
https://www.paramounthealthcare.com/services/providers/medical-policies/ .
PG0049 – 04/01/2021REVISION HISTORY EXPLANATION
ORIGINAL EFFECTIVE DATE: 01/11/2012
Date Explanation & Changes
Removed codes 71260 and 71270
ICD-10 Codes added from ICD-9 conversion
CT screening for lung cancer in heavy smokers is now covered for all members per TAWG review
03/21/2014
with prior authorization following the USPSTF recommendations
Procedure S8092 is non-covered for Advantage per The Ohio Department of Medicaid.
Policy reviewed and updated to reflect most current clinical evidence per TAWG
Added codes S8032 & 76497
Removed codes 71250 & S8092
11/10/2015
Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering
Committee
Added HCPCS codes G0296 & G0297, ICD-9 code V15.82 and ICD-10 code Z87.891
Removed CPT code 76497, HCPCS code S8032, ICD-9 code V76.0 and ICD-10 code Z12.2
CT screening for lung cancer in heavy smokers (G0296, G0297) covered with prior authorization for
01/12/2016 HMO, PPO, Individual Marketplace, & Elite
Procedures G0296 & G0297 are non-covered per The Ohio Department of Medicaid
Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering
Committee
Added code S8032 as covered for Advantage only with prior authorization
06/14/2016 Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering
Committee
HCPCS code S8032 deleted effective 09/30/16
Effective 01/01/17 code G0297 is now covered for Advantage per ODM guidelines
01/10/2017
Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering
Committee
Effective 10/01/17 code G0296 is now covered with prior authorization for Advantage per ODM
guidelines
06/13/2017
Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering
Committee
Added ICD-10 diagnosis codes F17.210, F17.211, F17.213, F17.218, F17.219 per CMS guidelines
Prior authorization requirement removed for Elite for low dose CT scan (LDCT) for lung cancer
screening in heavy smokers (G0296, G0297)
These services (G0296, G0297) must be billed with ICD-10 diagnosis codes F17.210, F17.211,
10/09/2018 F17.213, F17.218, F17.219, Z87.891 per CMS guidelines
ICD-9 code removed
Removed effective 09/30/16 deleted code S8032
Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering
Committee
Effective 1/1/2019: Procedure G0296 no longer requires a prior authorization for HMO, PPO,
01/01/2019
Individual Marketplace, & Advantage, per Administrative Medial Review/Determination
Effective 1/1/2019: Procedures G0296 and G0297 no longer require a prior authorization for all
02/01/2019
product lines, per Administrative Medical Review/Determination
01/01/2021 Medical policy placed on the new Paramount Medical Policy Format
Added new CPT code 71271-effective 1/1/2021
01/06/2021
Deleted code G0297-as of 12/31/2020
Medical Policy updated to the latest March 09, 2021 USPSTF Lung Cancer Screening
04/01/2021 Recommendations. The age populations’ span changed to 50-80 and the number of pack-year
requirement decreased to 20. The USPSTF grade is a B.
REFERENCES/RESOURCES
Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and
services
Ohio Department of Medicaid
PG0049 – 04/01/2021American Medical Association, Current Procedural Terminology (CPT®) and associated publications and
services
Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS
Release and Code Sets
U.S. Preventive Services Task Force, http://www.uspreventiveservicestaskforce.org/
Industry Standard Review
Hayes, Inc.
PG0049 – 04/01/2021You can also read
