TN 35 (08-20)

DI 23022.245 Non-Small Cell Lung Cancer




Squamous Cell Lung Carcinoma; Squamous Cell Lung Cancer; Large Cell Lung Carcinoma; Large Cell Lung Cancer; Adenocarcinoma of the Lung; Non-Small Cell Lung Carcinoma; Lung Carcinoma; Bronchioalveolar Carcinoma; Lepidic Adenocarcinoma


Lung Cancer forms in tissues of the lung, usually in the cells lining the air passages. The two main types are Small Cell Lung Cancer and Non-Small Cell Lung Cancer. Diagnosis of the type of cancer is based on microscopic examination. About 87% of lung cancers are Non-Small Cell Lung Cancers. This type spreads more slowly than Small Cell Lung Cancer. The three types of Non-Small Cell Lung Cancer are Squamous Cell Carcinoma, Large Cell Carcinoma, and Adenocarcinoma. Adenocarcinoma has a subdivision of bronchioalveolar carcinoma, which is also known as lepidic adenocarcinoma


Diagnostic testing: The following may be used to diagnose the extent of disease:

  • Physical exam history;

  • Chest x-ray;

  • CT scan;

  • PET scan;

  • Bronchoscopy;

  • Thorascoscopy;

  • Thoracotomy; or

  • Mediastinoscopy.

The diagnosis is made from the pathological evaluation of a tumor biopsy. Tumor can be obtained for pathology by needle biopsy or surgical excision.

Physical findings: Early lung cancer often does not cause symptoms. As the cancer progresses, common symptoms may include:

  • Persistent or worsening cough;

  • Breathing problems;

  • Constant chest pain;

  • Coughing up blood;

  • A hoarse voice;

  • Frequent lung infections;

  • Fatigue; or

  • Unintentional weight loss.

ICD-9: 162.3, 162.9, 231.2, 512.82, 795.81

ICD-10: C34.90


Diagnosis in the early stages provides the greatest chance for survival; however, symptoms of Non-Small Cell Lung Cancer usually do not appear until the disease is in an advanced stage. Treatment for Stage IV will not cure the cancer, but can reduce symptoms and extend and improve the quality of life.

The 5-year survival rate for Non-Small Cell Lung Cancer is 15%. Late stage Non-Small Cell Lung Cancer has a 5-year survival rate of less than 5%. Most Non-Small Cell Lung Cancer patients die within a year of diagnosis.


Treatment of Stage IIIB Non-Small Cell Lung Cancer may include surgery, external radiation therapy, chemotherapy, or a combination of all three. Treatment of Stage IV Non-Small Cell Lung Cancer may include internal radiation therapy, or external radiation as palliative therapy to relieve pain, symptoms, and improve quality of life.

Suggested MER for Evaluation:
  • A pathology report and an operative report are the preferred methods for documentation;

  • Clinical note from a surgeon that the cancer is inoperable; and

  • Surgical pathology report that the cancer was not completely removed and that the surgical margins were positive for malignancy.

“Inoperable” refers to a physician's opinion that surgery would not be beneficial based on a review of imaging studies, laboratory results, and physical examination findings. “Unresectable” cancer is established when the operative report indicates that the cancer is not completely removed or the pathology report notes that the surgical specimen has positive margins.
Suggested Listings for Evaluation:


Meets 13.14 A Non-Small Cell Lung Cancer that is inoperable, unresectable, recurrent, or with metastases to or beyond the hilar nodes meets the criteria in 13.14 A.
* Adjudicators may, at their discretion, use the Medical Evidence of Record or the listings suggested to evaluate the claim. However, the decision to allow or deny the claim rests with the adjudicator.

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DI 23022.245 - Non-Small Cell Lung Cancer - 08/31/2020
Batch run: 07/20/2021