MP-16 Low Dose Computed Tomography (LDCT) for Lung Cancer Form

Low‐Dose Computed Tomography (LDCT) for Lung Cancer

Current Effective Date: 5/8/2018
Original Effective Date: 5/8/2018
Next Review/Revision Date: 5/8/2019
Plans: QUEST Integration (Medicaid), AlohaCare Advantage Plus Special Needs Plan (SNP Medicare)

I. Definition
Computed tomography (CT) is an imaging procedure that uses specialized x‐ray equipment to create detailed pictures of areas inside the body.

Low‐Dose Computed Tomography (LDCT) is a chest CT scan performed at settings to minimize radiation exposure compared to a standard chest CT.

II. Criteria
A. LDCT is covered for lung cancer screening if the member meets all of the following criteria:

1. Between 55 and 80 years old.
2. Has no signs or symptoms of lung cancer, includes but not limited to unexplained cough, hemoptysis, or weight loss of more than 15 punds in the past year
3. Has a tabacco smoking hsiotry of at least 30 pack‐years (one pack‐year =smoking one pack per day for one year; 1 pack‐20 cigarettes)
4. Is a current smoker or has quit smoking within the last 15 years

5. Receives a written oder froma physician or qualified non‐physician practitioner.
   B. Before the first LDCT, the member must receive a counsling and shared decision making on the benefits and risks of lung cancer screening.
   C. LDCT is covered once per year.

   III. Guidelines
   Prior authorization is not required.

   IV. Coding Information
   The following medical codes are relevant codes for diagnosis and procedures for LDCT for Lung Cancer and should be used for informational purposes only. All the medical codes listed in this policy do not constitute or imply benefit coverage or guarantee provider reimbursement.

   ICD‐10
   Description
   F17.210
   Nicotine dependence, cigarettes, uncomplicated
   Medical Policy

F17.211
Nicotine dependence, cigarettes, in remission
Z72.0
Tobacco use
Z87.891
Personal history of nicotine dependence

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Low‐Dose Computed Tomography for Lung Cancer Screening

HCPCS
Description
G0296
Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan
G0297
Low dose CT scan (LDCT) for lung cancer screening
S8032
Low‐dose computed tomography for lung cancer screening (not covered by Medicare)

V. References/Resources
Document Name
Effective Date Source/Link
Lung Cancer Screening Version I
2016
National Comprehensive Cancer Network (NCCN)
http://www.nccn.org/professionals/physician_gls/pdf/ lungscreening.pdf
What Screening Tests Are There
01/28/2016 Centers for Diseases Control and Prevention http://www.cdc.gov/cancer/lung/basicinfo/screening .htm
National Coverage 02/05/2015 Centers for Medicare & Medicaid Services Determination (NCD) for Lung https://www.cms.gov/medicare‐coverageCancer Screening with Low Dose database/details/ncd‐ Computed Tomography (LDCT)
details.aspx?NCDId=364&ncdver=1&bc=AAAAgAAAAA (210.14)
AAAA%253d%253d&
Low‐Dose Helical (Spiral)
04/24/2015
Hayes.
Computed Tomography for Lung https://www.hayesinc.com/subscribers/displaySubscri Cancer Screening berArticle.do?articleId=1919&searchStore=%24search type%3Dall%24icd%3D%24keywords%3Dlow%2Cdos e%2Cct%24status%3Dall%24page%3D1%24fromdate %3D%24todate%3D%24reporttypeoptions%3D%2 4 technologytypeoptions%3D%24organsystem_opti o Medical Policy

ns%3D%24specialty_options%3D%24order%3Dasearc hRelevance
Screening for lung cancer: U.S. 2013 Annals of Internal Medicine 2014;160(5):330-8. DOI: Preventive Services Task Force 10.7326/M13-2771.
recommendation statement
http://www.ncbi.nlm.nih.gov/pubmed/24378917

Lung Cancer Screening

Centers for Disease Control and Prevention.
Guidelines and
https://www.cdc.gov/cancer/lung/pdf/guidelines.pdf
Recommendations

VI. Review/Revision History
5/8/2019 - Retired

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