GENERAL INFORMATION

It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations..

Policy
INDICATIONS FOR LOW-DOSE CT (LDCT) FOR LUNG CANCER SCREENING
For Annual Lung Cancer Screening: 
The use of low-dose, non-contrast spiral (helical) multi-detector CT imaging as a screening technique for lung cancer is considered medically necessary ONLY when used to screen for lung cancer for certain high-risk, asymptomatic individuals, i.e., no acute lung-related symptoms, when ALL of the following criteria are met:¹

Group 1:

• Individual is between 50 – 80 years of age*; AND
• There is at least a 20 pack-year history of cigarette** smoking; AND
• If the individual is a former smoker, that individual had quit smoking within the previous 15 years.

*May approve for individuals over the age limit if the individual is a candidate for and willing to undergo curative treatment

**Annual screening refers to the use of cigarettes only; does not take other forms of smoking into the calculation (i.e., vaping, pipe, cigar, marijuana; see Rationale).

Group 2:
Yearly low-dose CT surveillance after completion of definitive treatment of non-small cell lung cancer as per these parameters:²

• Stage I – II (treated with surgery +/- chemotherapy)
  • Starts at year 2 – 3 of surveillance
• Stage I – II (treated primarily with radiation) or stage III-IV with all sites treated with definitive intent
  • Starts at year 5 of surveillance 

Nodule on initial LDCT (Follow-up low dose CT is approvable):³

• Table 1 shows the follow-up interval at which LDCT can be approved to reduce radiation dose²
• If multiple nodules, the largest and type is used for decision

Other Indications
Further evaluation of indeterminate findings on prior imaging (unless follow up is otherwise specified within the guideline):

• For initial evaluation of an inconclusive finding on a prior imaging report that requires further clarification
• One follow-up exam of a prior indeterminate MR/CT finding to ensure no suspicious interval change has occurred (No further surveillance unless specified as highly suspicious or change was found on last follow-up exam.)

Table 1: Lung-RADS^® Assessment Categories²

Rationale
Smoking-related lung cancer is the leading cause of cancer deaths in both men and women in the United States. Treatment for most lung cancer is focused on surgery which is usually curative only when the tumors are very small. Screening for early lung cancer with sputum cytology and chest X-rays has not been successful in reducing deaths from lung cancer. However, in 2011, a large, prospective, multicenter trial was published that showed CT Chest screening identified early cancers better than other approaches and reduced the death rate from lung cancer. In 2014, the United States Preventive Service Task Force (USPSTF) recommended annual low-dose CT Chest screening (CPT^® code 71271) for people with current or recent past smoking histories. 

The health effects of smoking (tobacco) products other than cigarettes is limited. More research is needed to explore the cancer risk from these products to guide cancer prevention efforts; therefore, cancer screening guidelines have not been developed for them. Currently, the screening guidelines apply only to cigarettes smoking.

All screening and follow-up chest CT scans to be performed at low dose (100 – 120 kVp and 40 – 60 mAs), unless evaluating mediastinal findings or lymph nodes, where standard dose CT with IV contrast may be more appropriate.⁴

OVERVIEW
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.

References

1. Final Recommendation Statement Lung Cancer: Screening U.S. Preventive Services Task Force (USPSTF). Updated March 9, 2021. Accessed November 20, 2022. https://uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening
2. Lung‐RADS® Version 1.1. American College of Radiology (ACR). Updated 2019. Accessed November 20, 2022. https://www.acr.org/-/media/ACR/Files/RADS/Lung-RADS/LungRADSAssessmentCategoriesv1-1.pdf
3. Wood DE, Kazerooni EA, Baum SL, et al. Lung Cancer Screening, Version 3.2018, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. Apr 2018;16(4):412-441. doi:10.6004/jnccn.2018.0020
4. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Non-Small Cell Lung Cancer Version 1.2023. National Comprehensive Cancer Network (NCCN). Updated December 22, 2022. Accessed January 23, 2023. https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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