Medicare to cover radiation screenings for long-time smokers, spending billions

Agency follows task force recommendation to reimburse for low-dose radiation lung cancer screenings in high-risk patients.

Medicare has decided to cover low-dose radiation CT scan screenings for lung cancer in high-risk patients, a decision that could add to billions in reimbursements.

Following a 2013 decision by the U.S. Preventive Service Task Force mandating reimbursement by private insurers, Medicare will the procedure for patients who smoked a pack of cigarettes a day for an average of 30 years.

Patient advocates have praised the decision, but others are concerned about overuse, patient harm and the impact on the federal budget.

Though exact reimbursement will still be determined by the Centers for Medicare & Medicaid Services, iit is estimated that screening for eligible individuals could cost Medicare more than $9 billion for the scans, biopsies and treatments through 2020.

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"This is an important new Medicare preventive benefit since lung cancer is the third most common cancer and the leading cause of cancer deaths in the United States,” said Patrick Conway, MD, CMS chief medical officer and deputy administrator.

“We believe this final decision strikes an appropriate balance between providing access to this important preventive service and ensuring, to the best extent possible, that Medicare beneficiaries receive maximum benefit from a lung cancer screening program.”

Since the U.S. Preventive Service Task Force  gave low-dose CT lung cancer screenings a “B” rating, which required commercial insurers to cover it for similar high-risk patients as an essential health benefit without cost-sharing, advocates such as the Lung Cancer Alliance and American Lung Association have been urging Medicare to adopt the same coverage policy.

On the task force’s recommendation, healthcare providers like Ingalls Health System in suburban Chicago have marketed screenings in local communities, offering special pricing deals for patients, like those on Medicare, who would have to pay out of pocket.

As many as 5 million Medicare beneficiaries could meet the criteria for cancer screening this year, and last year, there were more than 224,000 new cases of lung cancer, according to the National Cancer Institute.

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"The coverage decision “will save lives and increase the low survival rates associated with lung cancer,” said Harold Wimmer, national president and CEO of the American Lung Association, which urged Medicare to cover the screening with less-restrictive criteria.

Others aren’t so sure that the benefits of early detection are worth the risks of false positives, invasive biopsies and grueling cancer treatment for patients who are not symptomatic. CMS’s nine-member Medicare Evidence Development and Coverage Advisory Committee initially voted against Medicare coverage for the screening tool last April.

The National Lung Screening Trial, a long-term study of 52,000 high-risk smokers, concluded that current and former heavy smokers ages 55 to 74 had a 15 to 20 percent lower risk of dying from lung cancer when screened with low-dose radiation CT scans, equivalent to about three fewer deaths per 1,000 people screened.

Of the lung masses detected in the study, 24 percent were determined to be non-cancerous false positives, although smaller thresholds for pulmonary nodules have been found to reduce the incidence of false positives and can let clinicians rule out the need for biopsies.

Twitter: @AnthonyBrino