evekhm/cms_iom_500 huggingface dataset:
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Among the organizations making recommendations for the selection of individuals for lung cancer screening, the American College of Chest Physicians (CHEST) has two recommendations. 1. For asymptomatic individuals age 55 to 77 who have smoked 30 pack-years or more and either continue to smoke or have quit within the past 15 years, we recommend that annual screening with low-dose CT should be offered. (Strong recommendation, moderate-quality evidence). 2. For asymptomatic individuals who do not meet the smoking and/or age criteria in Recommendation #1, are age 50 to 80, have smoked 20 pack-years or more and either continue to smoke or have quit within the past 15 years, we suggest that annual screening with low-dose CT should be offered. (Weak recommendation, moderate-quality evidence) (Mazzone, Panel Report 2021). Thus, for the smoking cessation history for persons who have quit smoking within the past 15 years, the American College of Chest Physicians (CHEST) guidelines recommend low dose CT since this is a strong recommendation.In the National Comprehensive Cancer Network (NCCN), Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Lung Cancer Screening Version 1.2021, the NCCN Lung Cancer Screening Panel defined the risk status of high risk as age  50 years and  20 pack-year history of smoking with these high-risk persons candidates for low dose CT (LDCT) screening (category 1) where shared  patient/physician decision-making is recommended, including a discussion of benefits/risks (NCCN, 2020). In addition, the most current National Comprehensive Cancer Network (NCCN) guidelines Version 1.2021 do not discuss the eligibility criterion for history of quitting smoking and this eligibility criterion is not included in the most recent NCCN guidelines Version 1.2021 recommendation statement on low dose CT screening (NCCN, 2020). There were no changes to the history of quitting smoking criterion in the updated 2021 NCCN guidelines Version 1.2022 (Wood, NCCN, 2021).
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
In summary of their recommendations, the American College of Radiology Appropriateness Criteria expert panel concluded that for Variant 1: Lung cancer screening with low-dose CT chest without IV contrast is usually appropriate in patients 55 to 80 years of age and 30 or more packs per year smoking history and currently smoke or have quit within the past 15 years. Variant 2: The panel did not agree on recommending lung cancer screening with low dose CT chest without IV contrast in patients 50 years of age or older and 20 or more packs per year history of smoking plus one additional risk factor. There is insufficient medical literature to conclude whether or not these patients would benefit from CT screening for lung cancer. Screening in this patient population is controversial but may be  appropriate. Variant 3: Lung cancer screening is usually not appropriate in patients younger than 50 years of age or older than 80 years of age or in patients of any age with less than 20 packs per year history of smoking and no additional risk factors (Donnelly, 2018). The American  College of Radiology recommends lung cancer screening with low dose CT for persons who have quit within the past 15 years.
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
The American Cancer Society 2013 guideline recommends that clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about screening with apparently healthy patients aged 55 years to 74 years who have at least a 30 [or more]pack-year smoking history and who currently smoke or have quit within the past 15 years (Wender, 2013). However, the 2013 American Cancer Society guideline is being updated and, in the meantime, the American Cancer Society recommends yearly lung cancer screening with low dose CT scans for people who: are 50 to 80 years old and in fairly good health, currently smoke, or have quit in the past 15 years, and have at least a 20 pack-year smoking history. The American Academy of Family Physicians gives the clinical preventive services recommendation for lung cancer screening in adults a B grade recommendation. The AAFP supports the United States Preventive Services Task Force (USPSTF) recommendation for annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery (AAFP, 2021). Both the American Cancer Society and the American Academy of Family Physicians  recommends lung cancer screening with low dose CT for persons who have quit within the past 15 years.We find the empiric evidence is sufficient to conclude that screening for lung cancer with low dose CT is reasonable and necessary for Medicare beneficiaries with the specific eligibility criterion for the quit smoking history of quitting smoking within the past 15 years. However, we find the human clinical evidence is not sufficient to conclude that screening for lung cancer with low dose CT is reasonable and necessary for Medicare beneficiaries with the specific eligibility criterion for the quit smoking history of quitting smoking more than 15 years ago. The Medicare beneficiary eligibility criterion for quitting smoking will not be changed and will remain at quitting smoking within the past 15 years. This recommended screening population for quitting smoking within the past 15 years does align with the 2021 USPSTF recommendation statement on low dose CT screening.
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Question 3: Is the evidence sufficient to determine that screening for lung cancer with low dose computed tomography is appropriate for Medicare beneficiaries?Lung cancer is a burdensome condition for the Medicare population due to the advanced stage and age at diagnosis and death. Early detection with various screening tests has been studied for many years without positive results but the benefits of low dose CT screening have been confirmed with extended  follow up data from the high quality NLST and NELSON trials. Based on the results of the NLST and NELSON, lung cancer screening using low dose CT was shown to reduce lung cancer mortality compared to screening with chest radiogram (x-ray) or no screening, respectively, for a very defined screening population including a broader portion of the Medicare population (aged 65 or greater). The low dose CT scan is relatively simple and attempts to balance radiation exposure to acceptable image quality, compared to standard diagnostic chest CT scans that are not appropriate for lung cancer screening.Counseling and Shared Decision-MakingDue to the complexities of lung cancer screening with LDCT including specific patient selection criteria, benefits, harms, and adherence, we continue to support the need for shared decision-making. However, we believe that the requirements should be modified to reflect a service that is no longer considered new. Professional societies and provider groups have noted that providers have gained considerable experience and expertise and believe flexibility will reduce burden. We will remove specificity regarding the type of provider who must furnish the counseling and shared decision-making and remove some specificity around documentation of the information on the beneficiary eligibility criteria.
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Several organizations have commented on the type of provider who should furnish shared decision-making. The American Thoracic Society (ATS) and American College of Chest Physicians (CHEST) policy statement (Wiener, 2015) includes comments on who should perform shared decision-making on low dose CT screening with the patient, which can include health educators or midlevel providers like lung cancer screening coordinator. The 2021 USPSTF recommendation (USPSTF, Krist; 2021) states that providers should engage in shared decision-making about screening, but there is no statement on who should conduct the shared decision-making with the patient or what level of the provider of shared decision-making should be. According to the American College of Chest Physicians (CHEST) guidelines for low dose CT lung cancer screening (Mazzone, Panel Report 2021), they do not provide detailed comments beyond the need for a screening program provider on who should deliver the shared decision-making visit to the patient. While the National Comprehensive Cancer Network (NCCN) guidelines recommend shared decision-making before an initial screening LDCT scan is performed (NCCN, 2020), the guidelines do not comment on who the provider should be for the shared decision-making discussion with the patient. The updated 2021 NCCN guidelines changed the terminology for shared decision-making from physician to provider (Wood, NCCN, 2021). None of the organizations specify what type of provider should conduct shared decision-making with the patient.We do not believe there is an evidentiary reason to continue to limit the shared decision-making visit to physician and non-physician practitioners. We note that this expansion can allow for this service to be furnished incident to a physicians professional service. Removing the specification for the type of practitioner should expand the individuals that can conduct shared decision-making to other health care practitioners, such as health educators and others beyond physicians or non-physician practitioners. Thischange may broaden access to LDCT screening.
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
While we continue to have the requirement for making an appropriate determination of the patients eligibility for lung cancer screening with low dose CT at the shared decision-making visit, it is no longer necessary to specify the documentation requirement. We believe stating this requirement under the subheading of documentation to be redundant and that the medical record will continue to reflect a patients eligibility and adherence to the eligibility criteria such as calculation of cigarettesmoking pack-years and years since quitting smoking; age; and absence of signs and symptoms of lung cancer Additionally, it is routine that the patients age is already in the patients medical records, since age is a fundamental sociodemographic characteristic that should already have been entered into the patients medical record at the initial clinical visit. Finally, smoking history in pack-years, years since quitting smoking, and absence of signs or symptoms of lung cancer is inherent in the clinical assessment of lung cancer.
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Several organizations have commented on the use of shared decision-making aids during the shared decision-making visit. According to the American College of Chest Physicians (CHEST) guidelines for low dose CT lung cancer screening (Mazzone, Panel Report 2021), shared decision-making is suggested prior to the performance of the low dose CT screening exam, and it is suggested that ordering providers have the tools necessary to deliver an effective counseling and shared decision-making, which may include decision aids, information brochures, videos, and links to electronic resources. The American Thoracic Society (ATS) and American College of Chest Physicians (CHEST) policy statement (Wiener, 2015) includes comments on shared decision-making as part of the low dose CT screening process and has examples of shared decision-making tools. Examples are provided of potential patient decision aid tools that could be used in shared decision-making by the provider with the patient (Wiener, 2015). While these guidelines suggest the use of shared decision aids during the shared decision-making visit, these guidelines do not specify the elements required as part of a shared decision-making tool. To reduce the burden of documentation paperwork, we will remove the specifications for the components of the shared decision-making tools. We believe this is appropriate as the tools and guidance has matured since the early inception of shared decision-making. Based on the organizations guidelines on shared decision-making tools, we determine that lung cancer screening with low dose CT is appropriate for Medicare beneficiaries who meet the other eligibility criteria and who participate in shared decision-making when the provider uses at least one decision aid.We will retain the eligibility criterion on counseling on the importance of adherence to annual lung cancer low dose CT screening, the impact of comorbidities, and ability or willingness to undergo diagnosis and treatment, since, as discussed above in the introductory comments on shared decision-making, these concepts are an integral and important component of the discussion of the benefits and harms of low dose CT lung cancer screening between the patient and provider and will have a majorimpact on the values attached to the patients preferences.We will retain the eligibility criterion for providing information on smoking cessation interventions within the shared decision-making visit.We are removing the excessive requirement for a written order. Additionally, having an order for the low dose CT screening test is standard practice and no longer needs to be specified as part of the NCD.
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
We are removing the excessive requirement for a written order. Additionally, having an order for the low dose CT screening test is standard practice and no longer needs to be specified as part of the NCD.We believe that removing the restriction for the type of practitioner who can furnish the counseling and shared decision-making visit, removing the specificity of redundant documentation requirements, and eliminating the excessive requirement for a written order will reduce administrative burden and facilitate improved access to lung cancer screening with LDCT.Smoking CessationWe will retain the furnishing of information on smoking cessation or smoking abstinence during the counseling and shared decision-making visit, based on the guidelines published by the societal organizations. Many guideline organizations discuss smoking cessation as an important part of low dose CT screening. For annual lung cancer screening with low dose CT in adults, the 2021 USPSTF recommendation has that if a person currently smokes, they should receive smoking cessation interventions. Further, persons referred for lung cancer screening through primary care should receive these interventions concurrent with a referral. Because many persons may enter screening through pathways besides referral from primary care, the USPSTF encourages incorporating such interventions into all screening programs (USPSTF, Krist; 2021). However, the 2021 USPSTF recommendation does not state within what setting that smoking cessation should occur in except that smoking cessation should occur within the setting of the screening program. The 2021 USPSTF recommendation also discusses other resources on smoking cessation developed by the Centers for Disease Control and Prevention and the National Cancer Institute.
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
In the section on shared decision-making, the National Comprehensive Cancer Network (NCCN) guidelines state that smoking cessation counseling is recommended (NCCN, 2020). Thus, while the NCCN guidelines recommend advising smokers to quit smoking tobacco, the guidelines do not explicitly comment on whether the discussion of smoking cessation should be part of shared decision-making. Additionally, the NCCN guidelines do not comment on the setting for the discussion of smoking cessation or when and where to discuss quitting smoking with the patient. The issue of setting remains unchanged in the updated 2021 NCCN guidelines (Wood, NCCN, 2021). According to the American College of Chest Physicians (CHEST) guidelines for low dose CT lung cancer screening (Mazzone, Panel Report 2021), evidence-based tobacco cessation treatment is recommended to be provided by the low dose CT screening program, even though the panel reported that the most effective intervention to promote smoking cessation in the setting of lung cancer screening is not known. The American Thoracic Society (ATS) and American College of Chest Physicians (CHEST) policy statements include comments on smoking cessation, but the statement notes that the best strategy to optimize smoking abstinence in the setting of LDCT screening is unknown (Wiener 2015). The ATS/CHEST policy statement (Wiener, 2015) does not comment on the setting, such as the specific imaging facility, for discussing smoking cessation with the patient or whether it should be included in shared decision-making. However, one organization suggests that smoking cessation intervention be integrated with shared decision-making. In the American College of Chest Physicians (CHEST) guidelines for low dose CT lung cancer screening (Mazzone, Panel Report 2021), counseling about smoking cessation is suggested as a component of thecounseling and shared decision-making visit of the patient with the clinical provider.
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
We will retain the requirement for furnishing information about tobacco cessation interventions or maintaining cigarette smoking abstinence within the shared decision-making visit. Given the current rates of smoking, we believe it is vitally important to provide information about tobacco cessation or cigarette smoking abstinence to the patient when possible. Based on the organizations guidelines on smoking cessation for low dose CT screening, we will retain the eligibility criterion that lung cancer screening with low dose CT is appropriate for Medicare beneficiaries who meet the other eligibility criteria and who have furnished information about tobacco cessation interventions if current smoker, or maintaining cigarette smoking abstinence if former smoker, during the shared decision-making visit. We determine that as a policy requirement for low dose CT screening as a radiology imaging facility eligibility criterion, it is not required for Medicare beneficiaries to receive smoking cessation interventions for current smokers within the setting of a radiology imaging facility, and that this eligibility criterion be removed from the radiology imaging facility eligibility criteria as part of this NCD.Written OrderWe will modify the criterion for a written order by removing the word written and removing the  data elements that are required as part of the order. As stated above, orders for lung cancer screening with LDCT are now standard practice and we no longer believe it is necessary to specify each data element on the order.While it is important and necessary for the facility to receive an order for the appropriate Medicare beneficiary to have a low dose CT scan to screen for lung cancer, the order does not have to be written since it is more likely that an order is transmitted electronically with the use of an electronic health record system. Additionally, the information we had previously specified is available in the medical record such as smoking history and years since quitting smoking, is in the patients medical records. Another reason for removing the detailed data elements is that we are removing the low dose CT lung cancer screening registry requirement and many of these elements were required as part of the registry data submission.Written Orders for Subsequent Annual Lung Cancer Screenings with Low Dose CTWe will remove the requirement for written orders for subsequent annual lung cancer screening with low dose CT. Consistent with our previous discussion, we believe that specifying the order be written is outdated and that orders for subsequent annual lung cancer screening with LDCT are standard practice and are no longer necessary as part of the NCD.
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo
Reading Radiologist Training and Eligibility CriteriaWe will modify the reading radiologist eligibility criteria by removing the training documentation requirement, the 300 chest CT acquisitions in 3 years requirement, the documented participation in continuing medical education in accordance with current American College of Radiology standards requirement, and the radiology facility eligibility criteria.We will retain the eligibility criterion that the reading radiologist must be board certified or board eligibility with the American Board of Radiology or equivalent organization in order to maintain the standards of the American Board of Radiology, the national medical specialty board that certifies radiologists. The mission of the American Board of Radiology is to certify that our diplomats demonstrate the requisite knowledge, skill, and understanding of their disciplines to the benefit ofpatients. . . . We were founded to protect the public by assessing and certifying doctors who meet specific educational, training, and professional requirements (American Board of Radiology, 2021). Further, [b]oard certification is the best measure of the knowledge, experience, and skills needed to provide quality patient care (American Board of Radiology, 2021). To maintain the standards of the American Board of Radiology, we will retain the eligibility criterion that lung cancer screening with low dose CT is appropriate for Medicare beneficiaries who meet the other eligibility criteria when the reading radiologist has board certification or board eligibility with the American Board of Radiology or equivalent organization.For initial board certification in diagnostic radiology, the requirements are that [a]s candidates progress through their residency and after completion of training, they will take two exams to gain initial certification in diagnostic radiology: the Core Exam and the Certifying Exam (American Board of Radiology, 2021). There is no mention of a requirement for additional training beyond residency training in diagnostic radiology and radiation safety, or the need for interpretation of at least 300 chest computed tomography acquisitions in the past three years. There is no subspecialty in CT scans. Thus, we will remove the eligibility criterion that the reading radiologist has documented training in diagnostic radiology and radiation safety, and to remove the other eligibility criterion that the reading radiologist be involved in the supervision and interpretation of at least 300 chest computed tomography acquisitions in the past 3 years, which should reduce the documentation paperwork burden on the provider.