Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after September 1, 2021, lung cancer screening benefits will change for Texas Medicaid.
Overview of Benefit Changes
Major changes to this medical benefit include the following:
- Expanded benefit information
- Addition of prior authorization guidelines
- Identification of excluded services
Preventive lung cancer screening that uses low dose computed tomography (LDCT) (procedure code 71271) is a benefit of Texas Medicaid once per year for asymptomatic high-risk clients meeting screening criteria. Screening may be initiated by a referral from a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). Physicians, PAs, NPs, and CNSs can order radiological procedures appropriate to their licensure.
Procedure code 71271 is a radiological procedure that provides high-resolution three-dimensional images of the lungs to detect lung nodules, which may indicate lung cancer in an asymptomatic high-risk client.
Lung cancer is commonly diagnosed in most clients when the disease is in an advanced stage and when the chances of curative therapy can be lower. Screening for early lung cancer detection can decrease mortality in high-risk clients. When used as a component of routine preventive screening, this might result in a more favorable treatment outcome.
Lung cancer commonly develops because of smoking for a greater number of years and many packs per day. A calculation derived from these numbers is referred to as pack years. A pack year of smoking history is defined as twenty cigarettes smoked daily for one year.
Potential risks that may be associated with LDCT lung cancer screening are false-positives and over-diagnosis that could result in further testing follow-ups. Additional risks include low dose cumulative exposure to low dose ionizing radiation over multiple years.
Client Eligibility Criteria
High-risk clients should be informed of tobacco smoking cessation counseling and that the annual lung cancer screening is not a substitute for smoking cessation.
The United States Preventive Services Task Force (USPSTF) has determined LDCT lung cancer screening to be a component of an annual routine health screening for clients who meet the high-risk category. Before the first annual LDCT lung cancer screening, the client should complete a counseling and shared decision-making visit with the provider, per the USPSTF Guidelines.
A high-risk client must meet all the following eligibility criteria for LDCT lung cancer screening, per the USPSTF:
- Be 50 through 80 years of age
- Have at least a 20-pack year smoking history
- Be a current smoker or have quit smoking within the previous 15 years
- Be asymptomatic (no signs or symptoms of lung cancer)
- Be engaged in shared decision-making about screening with their provider, including discussion of its potential health benefits, limitations, and harms
- Receive a referral for LDCT lung cancer screening, preferably to a facility with experience and expertise in lung cancer screening
A client that does not meet the USPSTF criteria for LDCT lung cancer screening but presents with chronic obstructive pulmonary disorder and associated symptoms (such as cough and shortness of breath), may also qualify for LDCT lung cancer screening.
A client is no longer eligible to receive annual LDCT lung cancer screening after meeting one or more of the following criteria, per the USPSTF:
- Non-smoker for 15 years
- Life expectancy is substantially limited
- The client is not willing or able to have curative lung surgery
Clients with signs or symptoms of lung cancer are not eligible to receive LDCT lung cancer screening. Symptomatic clients should undergo a diagnostic work up that is appropriate to their clinical presentation. Presumptive lung cancer signs or symptoms that are not attributable to other causes may include the following:
- An unexplained cough
- A cough producing blood (hemoptysis)
- Unexplained weight loss of greater than 15 pounds in the last 12 months
- Abnormal chest x-ray, presence of bony or soft tissue masses in combination with abnormally enlarged or changed consistency of the lymph nodes (lymphadenopathy)
Prior authorization must be obtained before performing LDCT lung cancer screening (procedure code 71271). Approved prior authorization requests will be valid for up to 90 days.
The client’s ordering provider must submit a prior authorization request on the Radiology Contractor Prior Authorization Request Form, which must include all the following documentation:
- The client’s diagnosis
- A statement confirming that the patient meets all the eligibility criteria for LDCT lung cancer screening
- Client’s current smoking status — current smoker or non-smoker with less than 15 years since their quit date
Prior authorization requests for procedure code 71271 may only be approved for clients with one of the following diagnosis codes, which must be included on the Radiology Contractor Prior Authorization Request Form:
Prior authorization for LDCT lung cancer screening is considered on an individual basis, adhering to standard clinical evidence-based guidelines. Documentation must support medical necessity for the service and must be maintained in the client’s medical record, both by the ordering physician and the performing facility.
Refer to: The current Texas Medicaid Provider Procedures Manual, Radiology and Laboratory Handbook, subsections 18.104.22.168, “Request Form and Documentation” and 22.214.171.124, “Methods of Submission,” for additional information about submitting prior authorization requests for CT services.
Annual LDCT lung cancer screening is not covered for any indications other than the possibility of lung cancer.
The following services are not a benefit of Texas Medicaid:
- Screening for clients who do not meet the high-risk criteria
- Positron emission tomography (PET), which is considered investigational and experimental for lung cancer screening and is therefore excluded as a lung cancer screening benefit since the effectiveness of PET for lung cancer screening has not been established
- Chest radiography and sputum cytology, which are not valid methods for lung cancer screening and are not covered benefits for lung cancer screening
- LDCT lung cancer screening using the following methods of testing:
- Computer-aided detection with physician review and interpretation of digital film or radiographic images of chest
- Computed tomography of thorax without contrast
- LDCT lung cancer screening for the following diagnosis codes: F17200, F17201, F17203, F17208, F17209, F17220, F17221, F17223, F17228, F17229, or Z77090
For more information, call the TMHP Contact Center at 800-925-9126.