CMScript 12 of 2021: Lung Cancer

“Cancer of lung, bronchus, pleura, trachea, mediastinum & other respiratory organs – treatable” are included in the Prescribed Minimum Benefit conditions under Diagnosis and Treatment Pair (DTP) code 950D.

Lung cancer develops when lung cells grow uncontrollable and abnormal. These cells then grow into a mass or tumour and may invade surrounding tissues and organs. They may also spread to other parts of the body. In 2018, more than 2 million new cases of lung cancer were reported worldwide. In the same year, almost 1.8 million lung cancer deaths occurred worldwide, and this figure represents 18.4% of all cancer related deaths.

According to the PMB regulation, treatable cancers are defined as follows:

1. they involve only the organ of origin and have not spread to adjacent organs;
2. there is no evidence of distant metastatic spread;
3. they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example, brain stem compression caused by a cerebral tumour) or another vital organ;
4. if points (i) to (iii) do not apply, there is a well demonstrated five-year survival rate of greater than 10% for the given therapy for the condition concerned.

PMB level of care for DTP code 950D, medical schemes must fund for the “medical and surgical management, which includes chemotherapy and radiation therapy” as specified for DTP code 950D. The medical schemes must pay for PMBs’ diagnosis, treatment, and care according to the PMB Regulations irrespective of the member’s plan type. Screening with a CT scan is not a PMB level of care.

The Council for Medical Schemes has published the PMB Definition Guidelines for small lung cancer, non-small cancer, and mesothelioma. These provide detailed information on the tests and treatment options that are PMB level of care and those that are not.

Download the CMScript here.