This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions

Medical Policy Search
Printer Friendly Version Screening for Lung Cancer Using Computed Tomography (CT) Scanning

Screening for Lung Cancer Using Computed Tomography (CT) Scanning

 

DESCRIPTION

 There is interest in screening and early identification of lung cancer because the disease, when identified clinically, tends to have a poor prognosis. Two proposed screening methods are chest radiographs and low-dose computed tomography (CT) scans. Either of these can be used with or without computer-assisted detection (CAD). Due to biases inherent in screening studies, randomized trials evaluating reduction in lung cancer morbidity and mortality are required to demonstrate the efficacy of screening.

Given the poor prognosis of lung cancer, there has been longstanding research interest in developing screening techniques for those at high risk. Previous studies of serial sputum samples or chest x-rays failed to demonstrate that screening improved health outcomes. More recently, there has been interest in low-dose computed tomography (CT) scanning as a screening technique, using either spiral (helical) or electron beam (ultrafast) CT scanning. Compared to conventional CT scans, these scans allow for the continuous acquisition of images, thus shortening the scan time and radiation exposure. A complete CT scan can be obtained within 20 seconds, or during one breath hold, in the majority of patients. The radiation exposure for this examination is greater than for that of a chest x-ray, but less than for a conventional CT scan.

There are also growing applications of computer-assisted detection or diagnosis (CAD) technologies that may have an impact on the use of CT scanning or chest radiographs for lung cancer screening. Computer-assisted detection points out possible findings to the radiologist who then decides if the finding is abnormal. Computer-assisted diagnosis uses a computer algorithm to analyze features of a lesion to determine the level of suspicion and is intended to enhance the reader's diagnostic performance. Both of these technologies may be expected to offer more benefit when used by relatively inexperienced readers and may help to standardize diagnostic performance.

In March 2001, the U.S. Food and Drug Administration (FDA) approved the RapidScreen RS-2000 system as a computer-aided detection (CAD) system intended to identify and mark regions of interest on digitized chest radiographs.  In February 2004, the U.S. Food and Drug Administration (FDA) approved the R2 Technology ImageChecker CT system as a technique to assist in the detection of lung nodules on multi-detector CT scans of the chest. The R2 Technology ImageChecker also received FDA clearance for the Temporal Comparison software module in June 2004 and for the CT-LN 1000 in July 2004. The Temporal Comparison software module provides the ability to automatically track lung nodule progression or regression over time. The ImageChecker CT-LN 1000 is used for the detection of solid nodules in the lungs. Other systems that have been developed include iCAD's Second Look CT lung and Siemens' Syngo LungCARE CT.

Also, see the related medical policy, Whole Body Computed Tomography Scan as a Screening Test.

 

POLICY

 Low-dose computed tomography (CT) scanning, no more frequently than annually for 3 consecutive years, may be considered medically necessary as a screening technique for lung cancer in individuals who meet ALL of the following criteria*:
  • Between 55 and 74 years of age
  • History of cigarette smoking of at least 30 pack-years
  • If former smoker, quit within the previous 15 years

* patient selection criteria are based on the National Lung Screening Trial (NLST)
Low-dose CT scanning is considered investigational as a screening technique for lung cancer in all other situations.

 

POLICY EXCEPTIONS

 Federal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.

 

POLICY GUIDELINES

 This policy does not apply to individuals with signs and/or symptoms of lung disease. In symptomatic individuals, a diagnostic work-up appropriate to the clinical presentation should be undertaken, rather than screening.

Although there is no specific CPT code for spiral or electron beam CT scanning, CPT code 71250 (computerized axial tomography, thorax) may be used. Thus the distinction between medically necessary CT scans of the thorax and spiral or electron beam CT scans as a screening test cannot be based on CPT code alone. ICD-9 code V76.0 is defined as special screening for malignant neoplasms of the respiratory organs. Thus, when used in conjunction with CPT code 71250, these codes may identify spiral or electron beam CT scanning as a screening test for lung cancer.
The optimal frequency of CT screening is not known. However, the recommendation to screen selected individuals is based on the NLST, which screened individuals annually for 3 consecutive years.

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. 

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

 11/2000: Approved by Medical Policy Advisory Committee (MPAC)

7/3/2001: ICD-9 diagnosis code V76.49 deleted

2/14/2002: Investigational definition added

5/1/2002: Type of Service and Place of Service deleted

9/8/2003: Code Reference section updated, CPT 76499 deleted, ICD-9 diagnosis code V76.0 deleted

9/24/2004: Sources updated

3/28/2006: Coding updated. CPT4 2006 revisions added to policy

3/30/2006: Policy reviewed, no changes

5/18/2006: Policy revised. Revisions approved per Medical Policy Advisory Committee (MPAC)

6/21/2006: Coding reference section updated, CPT codes 0152T, 71250 added to policy, ICD-9 procedure code 87.41 code added to policy. ICD-9 diagnosis code range 162.2-162.9, 197.0, 231.2 deleted from policy.

12/19/2007: Coding updated per the 2008 CPT/HCPCS revisions.

1/6/2009: Policy reviewed, no changes

04/13/2010:  Policy title changed from "Helical Computed Tomography (Spiral CT) for Lung Cancer Screening" to "Screening for Lung Cancer Using Computed Tomography (CT) Scanning or Chest Radiographs." Policy description updated. Added link to related medical policy. Policy statement unchanged. FEP verbiage added to the Policy Exceptions section.

12/29/2010: Policy reviewed; no changes.

05/16/2012: Deleted "Chest Radiographs" from the policy title. Policy statement revised to state that low-dose computed tomography (CT) scanning, no more frequently than annually for 3 consecutive years, may be considered medically necessary as a screening technique for lung cancer in individuals who meet certain criteria.  Added the following statement to the policy guidelines:  This policy does not apply to individuals with signs and/or symptoms of lung disease. In symptomatic individuals, a diagnostic work-up appropriate to the clinical presentation should be undertaken, rather than screening. Deleted 0152T, 76376, 76377, and 76497 from the Code Reference section. Changed codes from non-covered to covered. Added 0174T, 0175T, and V76.0 to the Code Reference section as covered.

04/04/2013: Policy reviewed; no changes.

 

SOURCE(S)

 Blue Cross Blue Shield Association policy # 6.01.30

 

CODE REFERENCE

 This is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

Code Number

Description

CPT-4

0174T

Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation (List separately in addition to code for primary procedure)  (Added 05-16-2012)

0175T

Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation  (Added 05-16-2012)

71250

Computed tomography, thorax; without contrast material 

ICD-9 Procedure

87.41

Computerized axial tomography of thorax

87.42

Other tomography of thorax

ICD-9 Diagnosis

V

Special screening for malignant neoplasm of the respiratory organs (Added 05-16-2012)

HCPCS

 

 

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