Lung Cancer Screening Benefits to Change for Texas Medicaid

Date: August 13, 2021 Attention: Primary care Providers Effective Date: September 1, 2021Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event. Call to action: Effective for dates of service on or after September 1, 2021, lung cancer screening benefits will change for Texas Medicaid. 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. How this impacts providers: There is not a prior authorization requirement for procedure code 71271 with TCHP at this time. It is a benefit once per year with the following diagnosis codes. This benefit is intended for a high-risk members and must meet all the following eligibility criteria for LDCT lung cancer screening, per the United States Preventive Services Task Force (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 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)

Next steps for providers: Providers should share this communication with their staff. If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.For access to all provider alerts,log into: www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.