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Does Medicare cover lung cancer screening? Sioux Falls, 2026

A real $0 benefit, a four-part eligibility test almost nobody explains, and an age limit that stops three years before the government's own guideline does.

Big Sioux Benefits Data Desk

Published September 22, 2026 · 20 min read · Sourced from CMS.gov

Yes — Medicare Part B covers a lung cancer screening CT scan at $0 once a year, with no deductible and no coinsurance, but only if you meet a four-part test on the day you're screened: age 50 through 77, a 20-pack-year-or-greater smoking history, currently smoking or having quit within the last 15 years, and no symptoms of lung cancer. Miss any one of those four, and the scan you assumed was a routine, covered checkup turns into something billed very differently. This guide walks through exactly who qualifies, why the benefit trips people up in practice, what a follow-up scan actually costs if a spot turns up, and the real 2026 Medicare Advantage plan landscape in Minnehaha County.

Every figure here comes from a source we checked today: CMS's own coverage rule (National Coverage Determination 210.14), Medicare.gov, the U.S. Preventive Services Task Force, the American Lung Association's 2025 State of Lung Cancer report, a November 2025 JAMA study built on the National Health Interview Survey, CDC PLACES county data, CMS's 2026 Part A & B premium fact sheet, and KFF's own analysis of CMS prior-authorization data. No invented numbers, no "call for pricing."

Who actually qualifies for the free scan

Medicare's rule is specific on purpose — it answers the question in the first two sentences of this guide, but the four parts are worth seeing side by side, because all four have to be true at once:

Source: CMS National Coverage Determination 210.14 — Lung Cancer Screening with LDCT (effective February 10, 2022) and Medicare.gov — Lung cancer screenings.

A pack-year is the standard way smoking history gets measured for this benefit — smoking one pack of cigarettes a day for one year equals one pack-year, so a pack a day for 20 years and two packs a day for 10 years both clear the bar the same way. There's no partial credit and no rounding up: your provider has to document the number, not estimate it in the exam room.

Why screening works: the trial behind the benefit

This isn't a benefit Medicare added on a hunch. It traces to the National Lung Screening Trial (NLST), a federally funded study of more than 53,000 people at high risk for lung cancer, which found low-dose CT screening produced a 20% relative reduction in lung cancer mortality compared with chest X-ray, along with a small reduction in deaths from any cause, per the USPSTF's own recommendation statement summarizing the trial's results. A second major study, the Dutch-Belgian NELSON trial, found a similar pattern using a different screening interval — 181 lung cancer deaths in the screened group versus 242 in the unscreened control group over 10 years of follow-up.

CMS first added this benefit to Medicare on February 5, 2015, in decision memo CAG-00439N — narrower criteria than today's: ages 55 through 77, and a 30-pack-year history, matching the science available at the time. The February 2022 update that set today's rules (50 through 77, 20 pack-years) followed the USPSTF's own 2021 guideline expansion, which its modeling projected would move lung cancer deaths avoided per 100,000 people screened over a lifetime from 381 under the old criteria to 503 under the new ones — a real, sourced reason Medicare widened who qualifies, even if the upper age still lags the USPSTF's own number.

Source: USPSTF — Lung Cancer: Screening (Grade B, March 2021); CMS Decision Memo CAG-00439N (Feb. 5, 2015).

The visit most people skip, and why it matters

Before your very first LDCT screening, Medicare requires a separate counseling and shared decision-making visit — a real appointment where a doctor or qualified practitioner walks through the benefits and harms of screening, uses a decision aid, checks that you meet the four criteria, and counsels on smoking cessation if you still smoke, per CMS's coverage rule. It can happen the same day as the scan in some settings, but it has to happen, and it has to be documented as its own step.

This is the piece that most often goes sideways. If a clinic's workflow treats the counseling visit as a formality folded into the scan order instead of billing and documenting it as the distinct, required visit CMS specifies, the claim can land outside the preventive-benefit rules — and the scan that should have processed at $0 shows up with a bill attached. It isn't usually anyone trying to overcharge you. It's a documentation mechanic that's easy to get wrong once, on one visit, and hard to catch until the statement arrives.

Picture the two paths side by side. In the first, your provider schedules a separate appointment, walks through your smoking history, confirms you meet all four criteria, documents the visit with its own billing code, and then orders the scan — which processes as the $0 preventive benefit. In the second, a scheduler simply books "a lung scan" off a referral, the counseling conversation happens informally in the hallway or over the phone, and nothing gets coded as the distinct visit CMS requires — so when the claim reaches Medicare or your Medicare Advantage plan, it doesn't match the rule that makes it free. Same scan, same radiologist, same machine. Different paperwork, different bill.

The age Medicare didn't move: 77 vs. 80

Here's a gap almost nobody explains up front. The U.S. Preventive Services Task Force — the federal panel whose recommendations set the standard for what preventive care "should" cover — updated its own guideline in March 2021 to recommend annual lung cancer screening for adults age 50 through 80, with a 20-pack-year smoking history, per the USPSTF's own recommendation statement. Medicare's coverage rule, finalized the following year, adopted the lower starting age of 50 and the lower 20-pack-year threshold — but capped the upper age at 77, not 80, per CMS NCD 210.14.

The practical result: a 78-year-old with the exact same smoking history and risk profile as a 77-year-old is, according to the USPSTF's own science, still a good candidate for screening — but Medicare doesn't pay for it anymore. Nothing about that person's risk changed at their last birthday. The coverage rule simply stops three years earlier than the guideline it's built on.

The American Cancer Society's own 2023 update goes further still, recommending screening based on smoking history regardless of how long ago someone quit — a real difference from Medicare's hard 15-year cutoff. Medicare's rule hasn't adopted that change either. None of this is a criticism of any one doctor's office; it's simply where the federal coverage rule currently sits, and it's worth knowing before you assume a scan will be free because it always has been.

What if you've never smoked?

Medicare's lung cancer screening benefit is built entirely around smoking history — there's no version of it for someone who has never smoked, no matter their age or family history. That gap matters more than it used to: a 2024 American Cancer Society and CDC study of more than 129,000 lung cancer cases found 12.5% of people newly diagnosed with lung cancer had never smoked — almost 16% of women and nearly 10% of men — with the highest share of never-smokers among people diagnosed at ages 20 to 49, per the American Cancer Society's own reporting on the study.

If you've never smoked, the $0 screening benefit simply doesn't apply to you under current Medicare rules, whatever your family history or environmental exposure. What does still apply: if you develop a symptom — a persistent cough, unexplained weight loss, coughing up blood — that's a reason for your doctor to order diagnostic imaging, billed under standard Part B rules rather than the preventive benefit. Radon exposure and secondhand smoke are both established risk factors independent of your own smoking history; if either concerns you, that's a conversation for your primary care provider, not something Medicare's screening rule currently accounts for on its own.

Source: American Cancer Society — More Than 12 Percent of Newly Diagnosed Lung Cancer Patients Never Smoked.

What it costs when the free scan stops being free

The screening itself — when you qualify and the paperwork is done right — costs $0. What catches people off guard is what happens next if the scan finds something. A nodule, a spot, anything that needs a closer look moves you out of the preventive-screening category and into diagnostic imaging, which runs under Medicare's ordinary Part B rules, not the $0 preventive rule.

For 2026, that means the standard $283 annual Part B deductible applies first, and then 20% coinsurance on whatever Medicare approves for the follow-up CT, PET-CT, or biopsy — with no dollar ceiling under Original Medicare alone, per CMS's own 2026 Parts A & B Premiums and Deductibles fact sheet, released November 14, 2025.

Source: CMS NCD 210.14; CMS Fact Sheet — 2026 Medicare Parts A & B Premiums and Deductibles (Nov. 14, 2025).

A Medigap (Medicare Supplement) plan is built specifically to close that second column. Plan G, the most common choice for people newly eligible for Medicare, covers 100% of the Part B coinsurance and the Part A deductible, leaving only the annual Part B deductible as an out-of-pocket cost, per CMS Publication 02110. If you have a Medicare Advantage plan instead, that diagnostic cost-sharing counts toward your plan's own annual out-of-pocket maximum — the number in your Evidence of Coverage, not a figure Original Medicare sets for you.

Here's what that looks like across the standardized Medigap plans people in this area actually buy. "Part B coinsurance" is the column that decides what a diagnostic follow-up scan costs you out of pocket:

Source: CMS — Choosing a Medigap Policy (Publication 02110); standardized plan benefits per 42 CFR §403.205.

Plan G pays the Part B coinsurance in full, so a person on Plan G who needs a diagnostic follow-up scan owes only the $283 2026 Part B deductible once for the year, and $0 after that on Medicare-covered imaging. Plan N leaves the same coinsurance covered but layers in small fixed copays for office and ER visits. Neither plan changes what the screening scan costs — that's already $0 for everyone who qualifies — they change what happens if that scan leads somewhere else.

The other free benefit: tobacco cessation counseling

If you're still smoking, there's a second, separate $0 Medicare benefit worth knowing about at the same visit: tobacco-use cessation counseling. Medicare covers up to 8 counseling sessions in a 12-month period — structured as up to 2 quit attempts a year, each with up to 4 sessions — for anyone who uses tobacco, at $0 when your provider accepts assignment, per Medicare.gov. It's billed separately from the lung cancer screening benefit and doesn't require you to already have a tobacco-related diagnosis to qualify for the counseling itself.

It's a small benefit next to a CT scan, but it's the one piece of this whole picture that can eventually take you out of the screening pool altogether — quit long enough, and in 15 years the annual scan requirement changes because your own risk profile changed. That's worth raising with your provider in the same appointment where you're being screened, not a separate errand for another day.

Source: Medicare.gov — Counseling to prevent tobacco use & tobacco-caused disease.

South Dakota's numbers

South Dakota isn't an outlier here — it's close to the national average on both ends, which is itself worth sitting with. According to the American Lung Association's 2025 State of Lung Cancer report, built on 2022 data:

Source: American Lung Association — State of Lung Cancer: South Dakota, 2022 data as published in the 2025 report; CDC PLACES: Local Data for Better Health, County Data 2023 (current cigarette smoking among adults, Minnehaha County, 2023, age-adjusted).

Only about 1 in 5 eligible Americans got screened for lung cancer in 2024. Full uptake among that same group would prevent an estimated 62,110 lung cancer deaths over five years — more than four times what current screening rates prevent. Potter et al., JAMA, November 19, 2025 — 2024 National Health Interview Survey

That JAMA study, published just this past November and built on the federal government's own 2024 National Health Interview Survey, put the national screening-eligible uptake rate at 18.7% — deaths prevented at that current pace: an estimated 14,970 over five years, versus 62,110 if every eligible adult were screened, per the study's own modeling. South Dakota's numbers sit almost exactly on that national line. Neither a crisis unique to this state, nor a problem that's solved.

Medicare Advantage and the prior-authorization wrinkle

A Medicare Advantage plan is legally required to cover at least everything Original Medicare covers, so the $0 lung cancer screening benefit carries over. What can differ is how a plan administers it. Some Medicare Advantage plans require prior authorization — the insurer's advance sign-off — before certain imaging, including LDCT screening, and the timing can matter: if the counseling visit and the scan are scheduled for the same day, but prior authorization wasn't secured before that date, the claim can be denied on a technicality that has nothing to do with whether you actually qualify.

How often does that kind of denial happen in Medicare Advantage generally? Nationally, insurers made 52.8 million prior-authorization determinations in 2024 and fully or partially denied 4.1 million of them — 7.7% — up from 6.4% in 2023, per KFF's own analysis of CMS data, released January 28, 2026. Only 11.5% of those denials were ever appealed. Of the people who did appeal, 80.7% won. That last number is worth sitting with: the overwhelming majority of appealed denials get overturned, which means most denials that stand, stand because nobody appealed — not because the plan was right.

How to get it right, step by step

None of this requires an insurance background. It requires doing the steps in order and asking direct questions before you show up, not after the bill does.

1. Check all four criteria yourself first. Age 50–77, 20+ pack-years, current smoker or quit within 15 years, no symptoms. Write down your actual smoking history in pack-years before your appointment — your provider will ask, and "about a pack a day for a long time" isn't the number that gets documented on the order.
2. Book the counseling and shared decision-making visit with your primary care provider, and ask directly whether it will be billed as its own separate visit, using the language "shared decision-making visit" so the front desk knows exactly what you mean.
3. If you have Medicare Advantage, call your plan first — the number on the back of your card — and ask whether LDCT lung cancer screening requires prior authorization for your specific plan, and if so, confirm it's approved before the scan is scheduled, not the same day it's performed.
4. Confirm the imaging facility participates in Medicare's screening benefit and uses a standardized nodule-reporting system, as CMS's coverage rule requires — your provider's referral should already route you to a qualifying facility, but it's fair to ask.
5. Keep a copy of your order and the visit summary. If a claim comes back wrong, this is exactly what your provider's billing office, and if needed Medicare itself, will want to see to correct it.
6. If a bill arrives for what you believed was the $0 screening, call your provider's billing office first — ask specifically whether the counseling visit was coded as preventive under NCD 210.14 — before you pay it.
7. If the scan finds something, know going in that the follow-up is diagnostic, budget for the 2026 $283 deductible and 20% coinsurance, and check whether your Medigap plan or Medicare Advantage out-of-pocket maximum limits your exposure.

The Sioux Falls plan landscape

Minnehaha County — 39,532 Medicare beneficiaries — has 5 standard Medicare Advantage PPOs open to anyone with Medicare for 2026, across 5 carriers. Every one of them must cover the lung cancer screening benefit at $0 for anyone who qualifies; what differs is the prior-authorization process, the premium, and the deductible on everything else:

Source: CMS Medicare Advantage / Part D Landscape (PY2026) & CMS Medicare Advantage & Part D Star Ratings (2026), Minnehaha County, plan year 2026.

All five carry the same CMS 3.5★ rating for 2026 — a average (3.5★) mark, per CMS's published measure — so the star rating alone won't tell you which plan handles a lung cancer screening prior-authorization request faster or with less friction. That's a question worth asking the plan directly, alongside your doctor's network status, before you enroll.

How we help

You can absolutely check your own eligibility using the four-part test above, and most people can. Where our clients most often want a second pair of eyes is exactly where this article's second half lives — the prior-authorization question on a Medicare Advantage plan, and what a Medigap plan would actually close if a follow-up scan is ever needed. Book a conversation and we'll walk through it with you, at no cost.

What you get

Clarity on whether the scan should cost you anything before you schedule it, instead of finding out from a statement three weeks later. A plan chosen with your actual smoking and health history in mind, not just the premium on a postcard — because a $0-premium plan that fights you on prior authorization isn't actually the cheaper choice once you count the phone calls. And if a claim does come back wrong, someone local who already knows the four criteria and the coding mechanics behind this specific benefit, so the first call isn't spent explaining pack-years to a stranger who's never heard the term.

None of that costs you anything to find out. Carriers, not clients, pay for the time we spend on this — which is also why we can say plainly when a plan doesn't fit rather than steering you toward whichever one pays best.

What to watch heading into the 2027 plan year

1. Confirm your own pack-year math before your next primary care visit — write it down, don't estimate it out loud.
2. Ask about prior authorization if you're on a Medicare Advantage plan, every year, since plan rules can change at renewal.
3. Watch whether Medicare's age cutoff moves — CMS periodically revisits National Coverage Determinations, and the USPSTF's 80-year ceiling is the obvious benchmark it hasn't yet matched.
4. Review your Annual Notice of Change each September for any shift in your plan's imaging cost-sharing or network.
5. If you're the one still smoking, ask about Medicare's separate, also-$0 smoking and tobacco-use cessation counseling benefit at the same visit — it's a distinct covered service from the screening itself.

How we know all this: Big Sioux Benefits runs every article through a data desk that cross-references CMS's own coverage rules and plan landscape data, the U.S. Preventive Services Task Force, the American Lung Association, peer-reviewed research, CDC county health data, and KFF's independent analysis of CMS claims data — built by Strategic AI Architects. Every figure above is sourced and dated. This is education, not medical or insurance advice; confirm your own eligibility and coverage with your doctor, a licensed agent, or Medicare.gov. We take no payment from any carrier or imaging center to feature it here.