February 17, 2017

Medicare Clarifies LCS Coverage Rules for IDTFs

In a written response to an inquiry from the American College of Radiology (ACR) and other imaging stakeholders, the Centers for Medicare & Medicaid Services (CMS) has affirmed that all facilities, that perform low-dose CT (LDCT) lung cancer screening must meet all the requirements described in the National Coverage Determination (NCD) for the procedure. This includes independent diagnostic testing facilities (IDTFs), as CMS did not make exclusions in terms of “all facilities”.

CMS issued a letter on Jan. 18, 2017, after receiving requests for clarification from the ACR, Radiology Business Management Association (RBMA), the Association for Quality Imaging (AQI), MedQuest Associates, and the Medical Imaging and Technology Alliance about Medicare coverage for LDCT lung cancer screenings performed by IDTFs.

In its response, CMS specifically concluded that “… all facilities that would like to receive Medicare coverage must meet all requirements in the NCD.” This means that all facilities, including IDTFs, may perform LDCT lung cancer screening and receive coverage/reimbursement if they meet the NCD requirements.

We agree with CMS that the Medicare Administrative Contractors (MACs) retain the authority to “make a determination” whether facilities (including IDTFs) that perform LDCT lung cancer screenings meet the NCD conditions for reimbursement. However, MACs are not authorized to withhold/deny coverage of a nationally implemented Medicare benefit for lung cancer screening purely based on the facility type (IDTF).

Please note that numerous MACs are not following the NCD as stated in CMS’ Jan. 18, 2017, response letter. More specifically for IDTF settings, many MACs are improperly excluding LDCT lung cancer screening coverage across the board, when performed in the IDTF setting, even for those sites that meet the NCD criteria. Certain MACs are not considering whether NCD criteria are met in an IDTF facility and are denying coverage to Medicare beneficiaries. This is in error and is resulting in patient access issues and decreased screening rates.

An ACR review of local MAC policies for IDTFs indicates that many facilities do not include lung cancer screening (G0297) on their procedures list. We have heard from numerous facilities that local MACs are denying lung cancer screening coverage when performed in the IDTF setting. It is clear there remains confusion among Medicare contractors, as Medicare beneficiaries have indeed had a lung cancer screening benefit since Feb. 5, 2015. This is defined in the lung cancer screening NCD and, therefore, the ACR will ask that MACs revise their IDTF policies to reflect this essential Medicare health benefit and to make payments retroactive to Feb. 5, 2015.

The ACR is working with key stakeholders to move lung cancer screening forward as it is performed in all facilities, including IDTFs, and to inform MACs about this nationally covered preventive service.