CMS expected to follow panel advice against CT scans for smokers

Some experts are predicting that the CMS will go along with Wednesday's controversial decision by an advisory panel not to recommend Medicare coverage of annual CT scans to detect lung cancer in heavy smokers.

The nine-member Medicare Evidence Development and Coverage Advisory Committee voted Wednesday that there is not enough research evidence to justify covering the scans.

The CMS expects to release a proposed decision memo in November, and, after taking public comment, it will issue a final national coverage determination by February 2015.

The unexpected MEDCAC decision runs counter to a December 2013 recommendation by the U.S. Preventive Services Task Force that current or past heavy smokers ages 55 to 80 should get the scans. Under the Patient Protection and Affordable Care Act, the task force's recommendation means that private insurers are required to cover the screening with no out-of-pocket obligation for their non-Medicare members. The test typically costs $300 to $400.

The task force made the decision based on the National Lung Screening Trial, which found a 20% reduction in deaths among current and former heavy smokers over age 55 who were screened using CT scans versus those screened using chest X-rays.

MEDCAC members did not question that the study showed people benefited from the CT screenings. But the panel expressed a lack of confidence that there was enough evidence annual scans would benefit people ages 65 and older.

Dr. Barry Straube, a former CMS chief medical officer who now is director of healthcare consulting for the Marwood Group, said that uncertainty increases the likelihood that the CMS will follow the committee's findings, since the advisory panel's role is to help the CMS determine whether there is sufficient scientific evidence that a medical service is both reasonable and necessary. “When the panel votes that the evidence isn't as strong as they'd like to see it, it's usually a sign that CMS may have some difficulties when it has their internal experts look into it,” he said.

Still, he added, Wednesday's vote “certainly doesn't preclude CMS from continuing its evaluation.”

Experts say there is precedent for the CMS to make national coverage determinations that go against MEDCAC recommendations or reverse its own coverage decision when there is significant political pressure from healthcare industry and patient groups.

In this case, some medical and patient advocacy groups, such as the American College of Radiology, strongly favor coverage for the annual CT scans. But it's unclear if there is broad enough support from the medical community or other political pressure to cause the CMS to reject the MEDCAC recommendation. The American Academy of Family Physicians in January concluded that there is inconclusive evidence to support offering annual CT scans. The academy said physicians and patients should engage in shared decisionmaking to weigh the potential benefits and harms.

At the meeting Wednesday, while patient advocates touted the benefits of the CT screening for lung cancer, the strongest push for the Medicare coverage of the test came from CT scan manufacturers and radiology clinicians, two stakeholder groups that would stand to gain financially if Medicare covers the annual scans.

Other observers also questioned the likelihood of the CMS granting coverage given MEDCAC's vote against coverage. Stéphane Lavertu, an assistant professor at Ohio State University who has studied MEDCAC decisions, said the likelihood of the CMS following the committee's decision generally is related to the committee's degree of consensus. On the question of CT scans for smokers, the majority of MEDCAC panelists gave the screening test low confidence ratings on each of the three voting questions.

But former CMS administrator Tom Scully, a general partner at private equity firm Welsh Carson Anderson & Stowe, said the CMS does not always follow MEDCAC recommendations. He recalls that when he signed off on expanding coverage for implantable cardiac defibrillators in 2003, he didn't expand coverage as widely as MEDCAC recommended. He said he made what he thinks was the best decision based on the advice of CMS medical experts. And he expects current CMS Administrator Marilyn Tavenner to do the same.

Follow Virgil Dickson on Twitter: @MHvdickson