Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

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If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 12/01/2014 Title: Lung Cancer Screening
Revision Date: 10/01/2019 Document: BI450:00
CPT Code(s): G0297
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    All CT scans, including low dose CT for lung cancer screening, require preauthorization.

2)    Low dose CT screening for lung cancer is covered under the preventive medicine benefit once a year for members ages of 55 to 80 who are smokers or former smokers who have smoked within the last 15 years and have at least a 30 pack year smoking history. 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.


Medical Statement

1)    USPSTF has given low dose CT (LDCT) screening for lung cancer a B rating and it will be eligible for coverage under the preventive medicine benefit when meeting the following criteria:

a.    Ages  55 to 80

b.    Have at least a 30 year pack history

c.    Have smoked within the past 15 years

d.    Once per year

e.    Not have a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

·         Patients with a diagnosis of COPD should have PFTs done before performing lung cancer screening by LDCT.  Per the American College of Chest Physicians (ACP), patients with an FEV1 less than 60 percent of predicted are not good candidates for lung surgery (and would therefore not qualify for LDCT screening).


Although the referring physician may use a variety of different diagnoses related to smoking, the facility performing the test and submitting the claim must use Z12.2 (Encounter for screening for malignant neoplasm of respiratory organs).

2)    LDCT is considered experimental/investigative for all other screenings

Codes Used In This BI:

G0297            Low-dose CT for lung cancer screening


Reference

1)    United States Preventive Services Task Force (USPSTF)

2)    Boushy SF, Billig DM, North LB, Helgason AH. Clinical course related to preoperative and postoperative pulmonary function in patients with bronchogenic carcinoma. Chest. 1971; 59(4):383.

3)    Colman NC, Schraufnagel DE, Rivington RN, Pardy RL. Exercise testing in evaluation of patients for lung resection. Am Rev Respir Dis. 1982; 125(5):604.

4)    Keagy BA, Lores ME, Starek PJ, Murray GF, and Lucas CL, Wilcox BR. Elective pulmonary lobectomy: factors associated with morbidity and operative mortality.  Ann Thorac Surg. 1985; 40(4):349.

5)    Boysen PG, Block AJ, Moulder PV. Relationship between preoperative pulmonary function tests and complications after thoracotomy. Surg Gynecol Obstet. 1981; 152(6):813.

6)    Miller JI, Grossman GD, Hatcher CR Pulmonary function test criteria for operability and pulmonary resection. Surg Gynecol Obstet. 1981; 153(6):893.

7)    Olsen GN, Block AJ, Swenson EW, Castle JR, Wynne JW. Pulmonary function evaluation of the lung resection candidate: a prospective study. Am Rev Respir Dis. 1975; 111(4):379.

Addendum: 

Effective 02/01/2018: 2017 Language clarified to more closely mirror USPSTF recommendations and first check PFTs if patient has COPD.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.