CT lung cancer screening/Medicare

so, yesterday Medicare proposed paying for lung cancer screening by low dose CT (LDCT) scans, though a somewhat less aggressive and better-conceived recommendation than that of the US preventive task force (USPSTF). (the Medicare proposal is still open to public comment for 30 days, but unlikely to change). the private insurers are locked-in legislatively (through the Affordable Care Act) to comply with the USPSTF recommendations by January 1, 2015, but Medicare has equivocated until now. The proposed recommendations for all Medicare beneficiaries who have at least a 30 pack-year history of smoking and is either a current smoker or has quit in the past 15 years:

--those aged 55-74 (vs 80 in USPSTF) would be entitled to annual LDCT screens. (the lower age would apply to those 480,000 Medicare beneficiaries under age 65 who get Medicare for certain disabilities). this would be yearly until either age 75, or if the person has quit smoking for 15 years (presumably based on older studies suggesting that after 15 years, the cancer risk regresses to near that of nonsmokers).
--there would need to be a written order by a clinician during a "lung cancer screening counseling and shared decision-making visit"
--there would be specific criteria for radiologist and imaging center participation
--subsequent screens should be ordered during an annual wellness visit, tobacco counseling session, or other visit
--they see this recommendation as applying to about 10 million Americans, with potential to save 20,000 lives/year

Note: the above is from a constellation of different websites: Medicare has no official pronouncement as of 8:15 AM 11/11/14, only apparent leaks to different regular and medical news organizations. A few improvements over USPSTF: 
    --Medicare clearly stresses the "shared decision-making" concept (which I think should include a detailed description of the very high false positive rate, the high likelihood of much more aggressive radiologic interventions/ionizing radiation exposure/creation of new cancers as outlined below, the potential for unnecessary surgery and its consequences, and even the unknown appropriateness of extending the LDCT surveillance from the 3 years in the study below to a potential of 20 years of screening)
    --Clear language/criteria for radiologists and imaging centers to ensure that the screen is really low-dose and the radiologists are qualified (again, the actual Medicare document is not currently available, so not sure of the specifics here)

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Addendum:

Medicare did finally publish their specific recommendations, pretty similar to what i sent out yesterday. to see the full set, go to: http://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=274 . this URL also contains their full, exhaustive analysis.

i copied below the specifics of the proposed content of the clinical visit (they did not specify the acceptable "decisions aids", noting "We believe that specific decision aids for lung cancer screening are being developed and will become more readily available as screening is more broadly adopted​".  more later....)

·         A lung cancer screening counseling and shared decision making visit includes the following elements (and is appropriately documented in the beneficiary’s medical records):

o    Determination of beneficiary eligibility including age, absence of signs or symptoms of lung disease, a specific calculation of cigarette smoking pack-years; and if a former smoker, the number of years since quitting;

o    Shared decision making, including the use of one or more decision aids, to include benefits, harms, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure;

o    Counseling on the importance of adherence to annual LDCT lung cancer screening, impact of comorbidities and ability or willingness to undergo diagnosis and treatment;  

o    Counseling on the importance of maintaining cigarette smoking abstinence if former smoker, or smoking cessation if current smoker and, if appropriate, offering additional Medicare-covered tobacco cessation counseling services; and

o    If appropriate, the furnishing of a written order for lung cancer screening with LDCT.  Written orders for both initial and subsequent LDCT lung cancer screenings must contain the following information, which must also be documented in the beneficiaries’ medical records:

§  Beneficiary date of birth,

§  Actual pack-year smoking history (number);

§  Current smoking status, and for former smokers, the number of years since quitting smoking; 

§  Statement that the beneficiary is asymptomatic; and

§  NPI of the ordering practitioner.