Humana Commercial Clinical Policy

Humana Lung Cancer Screening Form


Effective Date

09/28/2023

Last Reviewed

NA

Original Document

  Reference



Description

Lung cancer is often diagnosed at a late stage resulting in poor long term survival rates. Detecting the disease and initiating treatment at an early stage are important for improving survival. Cigarette smoking significantly increases the risk of lung cancer. The pack-year history indicates the amount of cigarettes an individual has smoked over a period of time and is calculated by multiplying the number of cigarette packs smoked per day by the number of years the individual has smoked.

A screening test recommended for lung cancer detection is low-dose computed tomography (LDCT), also known as spiral or helical CT scanning.

LDCT is a noncontrast radiographic technique that can provide high quality, three-dimensional images of the lungs during a single breath hold with less radiation exposure than conventional high resolution CT scanning. The purpose of LDCT screening is to identify the presence of lung cancer in an individual that does not demonstrate any symptoms.

Computer aided detection (CAD) systems

are diagnostic tools that purportedly assist radiologists in the detection of subtle findings to facilitate early cancer detection. Used as an adjunct to radiographic or CT images of the chest, it analyzes and highlights areas in the image that appear to be solid nodules, alerting the radiologist to the need for additional analysis. The CAD system consists of dedicated computer software and a review workstation. (Refer to Coverage Limitations section)

Other tests being evaluated for lung cancer screening include, but may not be limited to, chest radiograph (X-ray), positron emission tomography (PET) scan and sputum cytology. (Refer to Coverage Limitations section)

For information regarding topics related to lung cancer, please refer to:
  • Pharmacogenomic testing lung cancer - Pharmacogenomics Companion Diagnostics
  • Tumor markers for lung cancer - Emerging Tumor Markers for Diagnosis and Monitoring of Cancer

Coverage Determination

Humana members may be eligible under the Plan for lung cancer screening utilizing LDCT when the following criteria are met:

  • Asymptomatic individual between 50 and 80 years of age; AND
  • Current or former smoker with at least a 20 pack-year history of cigarette smoking; AND
  • Smoking cessation has occurred within the previous 15 years in former smokers; AND
  • No health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery; AND
  • Screening occurs no more frequently than once per calendar year (January 1 – December 31)

Note: The criteria for lung cancer screening utilizing LDCT are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage Limitations

Humana members may NOT be eligible under the Plan for lung cancer screening utilizing LDCT for asymptomatic individuals for any indications other than those listed above.

This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for lung cancer screening for asymptomatic individuals utilizing the following tests for any indication:

  • Chest radiograph (X-ray); OR
  • PET scan; OR
  • Sputum cytology

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for CAD for chest radiographs or CT for any indication. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Lung Cancer Screening Effective Date:

09/28/2023

Revision Date:

09/28/2023

Review Date:

09/28/2023

Policy Number:

HUM-0521-017

Page:

4 of 9

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Additional information about lung cancer screening may be found from the following websites:

Background

  • American Lung Association
  • National Cancer Institute
  • National Comprehensive Cancer Network
  • National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

HCPCS Code(s)
  • G0296 - Counseling visit to discuss need for lung cancer screening using low dose CT scan (LDCT) (service is for eligibility determination and shared decision making)

Lung Cancer Screening Effective Date:

09/28/2023

Revision Date:

09/28/2023

Review Date:

09/28/2023

Policy Number:

HUM-0521-017

Page:

6 of 9

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

References
  1. Agency for Healthcare Research and Quality (AHRQ). Screening for lung cancer with low-dose computed tomography: an evidence review for the US Preventive Services Task Force. https://www.ahrq.gov. Published March 2021. Accessed August 31, 2023.
  2. American Cancer Society (ACS). American Cancer Society lung cancer screening guidelines. https://www.cancer.org. Published January 2013. Accessed August 31, 2023.
  3. American Cancer Society (ACS). Cancer screening in the United States, 2018: a review of current American Cancer Society guidelines and current issues in cancer screening. https://www.cancer.org. Published May 30, 2018. Accessed August 31, 2023.
  4. American College of Chest Physicians (ACCP). Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. https://www.chestnet.org. Published May 2013. Accessed September 1, 2023.
  5. American College of Chest Physicians (ACCP). Guideline and Expert Panel Report. Screening for lung cancer. https://www.chestnet.org. Published July 13, 2021.
  1. American College of Radiology (ACR). ACR Appropriateness Criteria. Lung cancer screening. https://www.acr.org. Published 2018. Updated 2022. Accessed September 1, 2023.
  2. American College of Radiology (ACR). ACR–STR practice parameter for the performance and reporting of lung cancer screening thoracic computed tomography (CT). https://www.acr.org. Published 2014. Updated 2019. Accessed September 1, 2023.
  3. American Lung Association. State of lung cancer 2022 report. https://www.lung.org. Published 2022. Accessed September 1, 2023.

Lung Cancer Screening Effective Date:

09/28/2023

Revision Date:

09/28/2023

Review Date:

09/28/2023

Policy Number:

HUM-0521-017

Page:

7 of 9

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. American Thoracic Society (ATS). Research Statement. Incorporating coexisting chronic illness into decisions about patient selection for lung cancer screening. https://www.thoracic.org. Published July 15, 2018. Accessed September 1, 2023.
  2. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). Lung cancer screening with low dose computed tomography (210.14). https://www.cms.gov. Published February 5, 2015. Accessed August 30, 2023.
  3. ClinicalKey. Bevers TB, El-Serag H, Hanash S, et al. Screening and early detection. In: Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE. Abeloff’s Clinical Oncology. 6th ed. Elsevier; 2020:375-398.e7. https://www.clinicalkey.com. Accessed September 5, 2023.
  4. ClinicalKey. McWilliams A, Brims F, Horeweg N, et al. Screening for lung cancer. In: Pass, HI, Ball D. IASLC Thoracic Oncology. 2nd ed. Elsevier; 2018:52-58.e3. https://www.clinicalkey.com. Accessed September 5, 2023.
  5. ECRI Institute. Hotline Response (ARCHIVED). Bone suppression imaging for diagnosing lung cancer. https://www.ecri.org. Published May 20, 2014. Accessed August 30, 2023.
  6. ECRI Institute. Hotline Response (ARCHIVED). Single-reading plus computer-aided detection compared to double-reading of imaging exams for cancer screening. https://www.ecri.org. Published September 29, 2009. Updated May 24, 2012. Accessed August 30, 2023.
  7. ECRI Institute. Technology Forecast. Computed tomography with computer-aided detection for lung cancer screening. https://www.ecri.org. Published December 2, 2003. Updated February 9, 2015. Accessed August 30, 2023.
  8. Hayes, Inc. Medical Technology Directory (ARCHIVED). Low-dose helical (spiral) computed tomography for lung cancer screening. https://evidence.hayesinc.com. Published April 4, 2013. Updated March 13, 2017. Accessed August 30, 2023.

Lung Cancer Screening Effective Date:

09/28/2023

Revision Date:

09/28/2023

Review Date:

09/28/2023

Policy Number:

HUM-0521-017

Page:

8 of 9

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. Jaklitsch M, Jacobson F, Austin J, et al. The American Association for Thoracic Surgery guidelines for lung cancer screening using low-dose computed tomography scans for lung cancer survivors and other high-risk groups. J Thorac Cardiovasc Surg. 2012 Jul;144(1):33-8. https://www.jtcvs.org. Accessed September 7, 2022.
  2. MCG Health. Chest CT scan. 27th edition. https://www.mcg.com. Accessed August 28, 2023.
  3. MCG Health. Tumor imaging positron emission tomography (PET) and PET-CT. 27th edition. https://www.mcg.com. Accessed August 28, 2023.
  4. National Cancer Institute (NCI). Lung cancer screening (PDQ) – health professional version. https://www.cancer.gov. Updated June 9, 2023. Accessed August 31, 2023.
  1. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Lung cancer screening. https://www.nccn.org. Updated July 19, 2023. Accessed September 1, 2023.
  2. UpToDate, Inc. Approach to the adult survivor of classic Hodgkin lymphoma. https://www.uptodate.com. Updated July 2023. Accessed August 30, 2023.
  3. UpToDate, Inc. Evaluation and management of lung cancer in patients with interstitial lung disease. https://www.uptodate.com. Updated July 2023. Accessed August 30, 2023.
  4. UpToDate, Inc. Evidence-based approach to prevention. https://www.uptodate.com. Updated July 2023. Accessed August 30, 2023.
  5. UpToDate, Inc. Magnetic resonance imaging of the thorax. https://www.uptodate.com. Updated July 2023. Accessed August 30, 2023.
  6. UpToDate, Inc. Screening for lung cancer. https://www.uptodate.com. Updated July 2023. Accessed August 30, 2023.

Lung Cancer Screening Effective Date:

09/28/2023

Revision Date:

09/28/2023

Review Date:

09/28/2023

Policy Number:

HUM-0521-017

Page:

9 of 9

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  1. US Preventive Services Task Force (USPSTF). Recommendation Statement. Screening for lung cancer. https://www.uspreventiveservicestaskforce.org. Published March 9, 2021. Accessed August 31, 2023.
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