Statutory and Provider Background to CMS’ Decision to Pay for Some Low Dose CT Scans for Lung Cancer

More on CMS paying for some low dose CT scans.

CMS received two requests to pay for some low dose CT scans.  Ultimately, CMA agreed to pay for some low dose CT scans based based on some of the governing statutory criteria. The  Decision Memo explained the following regarding the background:

“A. Current Request

CMS received two formal requests for a national coverage determination (NCD) for lung cancer screening with LDCT, one from Peter B. Bach (Director, Center for Health Policy and Outcomes, Memorial Sloan-Kettering Cancer Center), and another from Laurie Fenton Ambrose (President & CEO, Lung Cancer Alliance). The formal request letters can be viewed via the tracking sheet for this NCA on the CMS website at http://www.cms.gov/medicare-coverage-database/details/nca-tracking-sheet.aspx?NCAId=274.

“III. History of Medicare Coverage

Pursuant to §1861(ddd) of the Social Security Act, the Secretary may add coverage of “additional preventive services” if certain statutory requirements are met. Our regulations provide: 42 CFR §410.64 Additional preventive services (a) Medicare Part B pays for additional preventive services not described in paragraph (1) or (3) of the definition of “preventive services” under §410.2, that identify medical conditions or risk factors for individuals if the Secretary determines through the national coverage determination process (as defined in section 1869(f)(1)(B) of the Social Security Act) that these services are all of the following: (1) Reasonable and necessary for the prevention or early detection of illness or disability. (2) Recommended with a grade of A or B by the United States Preventive Services Task Force. (3) Appropriate for individuals entitled to benefits under part A or enrolled under Part B. (b) In making determinations under paragraph (a) of this section regarding the coverage of a new preventive service, the Secretary may conduct an assessment of the relation between predicted outcomes and the expenditures for such services and may take into account the results of such an assessment in making such national coverage determinations.”

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Since becoming a lawyer in 1983, Kirk’s over 30 years of practice have focused on advising a wide range of corporations, associations, and individuals (as both plaintiffs and defendants) on both tort and commercial law issues centered around “mass torts.”

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