CMS expected to accept panel's advice not to cover smokers' CT scans

Some experts predict the CMS will go along with the controversial decision by an advisory panel last week not to recommend Medicare coverage of annual CT scans to detect lung cancer in heavy smokers.

The nine-member Medicare Evidence Development & Coverage Advisory Committee determined that there is not enough research evidence to justify covering the scans. The CMS expects to release a proposed decision memo in November. After taking public comment, it will issue a final national coverage determination by February 2015.

The unexpected MEDCAC decision runs counter to a December recommendation from the U.S. Preventive Services Task Force advising that current or past heavy smokers ages 55 to 80 should get the scans. Under the healthcare reform law, the task force's recommendation means that private insurers are required to cover the screening—which typically costs between $300 and $400—with no out-of-pocket obligation for their non-Medicare members.

The task force made its 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, compared with those who were screened using chest X-rays. Despite that study, MEDCAC members doubted there was enough evidence that 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 MEDCAC's findings. But the committee's vote “doesn't preclude CMS from continuing its evaluation,” he said.

There is precedent for the CMS to bow to political pressure in making national coverage decisions. In this case, the strongest push for coverage came from CT scan manufacturers and radiology clinicians, including the American College of Radiology. But the American Academy of Family Physicians in January said there is inconclusive evidence to support offering annual CT scans.

Stéphane Lavertu, an assistant professor in public affairs at Ohio State University who has studied MEDCAC decisions, said the likelihood of the CMS following a committee decision is generally related to the panel's degree of consensus, and there was strong consensus in this case.

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, depending on the advice it receives from its internal medical experts.

Follow Virgil Dickson on Twitter: @MHVDickson