Medicare covers annual lung cancer screening for beneficiaries who meet specific high-risk criteria. This preventive service utilizes a Low-Dose Computed Tomography (LDCT) scan, which is a specialized X-ray procedure that takes multiple images of the lungs to detect abnormalities. The goal of this annual screening is to find lung cancer at its earliest stages, which significantly improves the chances of successful treatment. Coverage for this service is provided under Medicare Part B, which handles outpatient care and preventive services.
Medicare Eligibility Requirements for Screening
Medicare Part B covers annual lung cancer screening for beneficiaries who fall into a high-risk category based on their age and smoking history. These specific criteria are established by the Centers for Medicare & Medicaid Services (CMS). To qualify, a person must be between the ages of 50 and 77 years old and must not show any current signs or symptoms of lung cancer.
Eligibility requires a smoking history of at least 20 pack-years. A pack-year is calculated by multiplying the average number of cigarette packs smoked per day by the number of years a person has smoked.
The beneficiary must either be a current smoker or a former smoker who has quit within the last 15 years. If a former smoker has maintained a non-smoking status for longer than 15 years, they no longer meet the high-risk definition for Medicare coverage.
The coverage is provided annually, meaning eligible beneficiaries can receive one LDCT scan every 12 months. The screening must be ordered by a physician or other qualified non-physician practitioner, and the procedure must be performed at a facility that meets specific requirements for image quality and radiation dose, ensuring patient safety and diagnostic accuracy.
Patient Costs for Lung Cancer Screening
Since lung cancer screening is classified as a preventive service under Medicare Part B, the LDCT scan itself is covered at 100% for eligible beneficiaries. This means that individuals who meet all the established criteria pay nothing—there is no copayment, coinsurance, or deductible applied to the annual screening procedure.
The required consultation that precedes the first screening, known as the Shared Decision-Making Visit, is also covered at no cost to the patient. This consultation is considered an integral and mandatory part of the preventive service and is therefore included in the 100% coverage.
However, it is important to distinguish between the preventive screening and subsequent diagnostic care. If the LDCT scan identifies a suspicious finding, any follow-up tests required to determine a diagnosis are no longer considered preventive. These diagnostic procedures, such as a biopsy, a PET scan, or a more detailed CT scan, are covered under standard Medicare Part B rules, meaning the patient is responsible for the Part B deductible and a 20% coinsurance.
Navigating the Screening Process and Follow-up Care
The process for utilizing Medicare’s lung cancer screening benefit begins with a required consultation called the Shared Decision-Making Visit (SDMV). This visit must occur before the first annual screening LDCT is performed and must be conducted by a qualified healthcare provider. The purpose of this mandatory discussion is to ensure the patient fully understands the procedure and its implications.
During the SDMV, the provider confirms the patient meets all the high-risk eligibility criteria and engages in a thorough discussion about the benefits and potential harms of the screening. This includes counseling on the possibility of false-positive results, which may lead to anxiety and unnecessary follow-up procedures, as well as the risk of overdiagnosis. The provider also emphasizes the importance of adhering to the annual screening schedule.
A significant component of the SDMV is counseling on smoking cessation, which is offered to all current smokers. This includes providing information about Medicare-covered services and resources available to help them quit. Following the successful completion of the SDMV, the provider will issue a written order for the initial LDCT scan.
If the initial LDCT scan detects a concerning nodule or abnormality, a second phase of care begins, shifting from screening to diagnosis. This follow-up care often involves additional imaging to monitor the finding or a more invasive procedure, such as a biopsy, to obtain a tissue sample. While the screening itself is cost-free, beneficiaries should be aware that these subsequent diagnostic tests fall under standard Part B coverage rules, which may involve out-of-pocket expenses.