Medical Policy: 06.01.19
Original Effective Date: February 2003
Reviewed: February 2018
Revised: February 2018
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This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
In the United States, lung cancer is the leading cause of cancer-related death among genotypical men and genotypical women. The most important risk factor for lung cancer is tobacco use. Other risk factors are small compared with cigarette smoke, these causal factors include exposures to environmental and occupational substances and family history of lung cancer. Most lung cancer patients are diagnosed when their disease is advanced. Due to the prevalence and mortality associated with lung cancer, there has been much interest in developing screening tests for lung cancer, in particular, for at-risk individuals at an earlier and more curable stage. Individuals with high risk factors who are candidates for screening should not have any symptoms suggestive of lung cancer (e.g. cough, pain, weight loss). The goal of screening is to detect disease at a stage when it is not causing symptoms and when treatment will be most successful. Screening should benefit the individual by increasing life expectancy and increasing quality of life.
Chest x-ray (CXR) and sputum cytology have been the most common methods used for screening lung cancer, but previous studies have failed to demonstrate that screening with these modalities resulted in improved health outcomes. More recently, low-dose computed tomography (LDCT) has been proposed as a method of screening asymptomatic, high risk individuals for lung cancer. LDCT refers to a non-contrast study with a multi-detector CT scanner during a single maximal inspiratory breath-hold with a scanning time of under 25 seconds. New multi-detector CT scanners generate high-resolution imaging with radiation exposure significantly less than for diagnostic CT scanning. It has been suggested that LDCT may be an improved early lung cancer detection tool based on the advantages it appears to have over CXR and sputum cytology to detect lung cancer at an earlier stage.
Shared patient and physician decision making may be the best approach before deciding whether to do LDCT lung cancer screening, especially for patients with comorbid conditions. Individuals who choose to undergo lung cancer screening should enter an organized screening program at an institution with expertise in LDCT screening, with access to a multidisciplinary team skilled in the evaluation, diagnosis and treatment of abnormal lung lesions.
While screening for lung cancer has the potential benefits of decreased morbidity and mortality from lung cancer it also has potential harms, which include:
- A lung cancer screening test can suggest that a person has lung cancer when no cancer is present, this is called a false-positive result. False positive results can lead to follow up tests or surgeries that are not needed and may have more risks.
- A lung cancer screening test can find cases of cancer that may never have caused a problem for the patient. This is called over-diagnosis. Over-diagnosis can lead to treatment that is not needed.
- Radiation from serial imaging in a screening program may add to the risk of developing cancers, including lung cancer. Since screening typically occurs over several rounds and positive studies require further evaluation, the cumulative radiation dose is also important.
National Lung Screening Trial
The National Lung Screening Trial (NLST) was a randomized trial sponsored by the National Institute of Health comparing the annual screening by low dose computed tomography (LDCT) scanning with standard chest x-ray for three years in 53, 454 high risk individuals at 33 United States medical centers. Participants were men and women 55 to 74 years of age with a history of at least 30 pack years of smoking, current smokers and those who had discontinued smoking within 15 years of enrollment. In 2013, the NLST researchers released their findings which found approximately 15 to 20 percent fewer lung cancer deaths among trial participants screened with low dose computed tomography (LDCT) compared to the participants screened with chest x-ray. The trial was stopped early after an interim analysis found a statistically significant benefit for low dose computed tomography scanning.
In 2013, a study by Kovalchik et. al. investigated whether the benefits and harms of low-dose CT screening in the NLST participants differed according to the participants' prescreening risk of lung cancer death. The participants were classified into two groups, a CT-screening group and a radiography group, and then into five quintiles for the predicted 5-year risk of death from lung cancer (with quintile 1 having the lowest risk and quintile 5 having the highest risk). The median follow-up was 5.5 years. The number of lung-cancer deaths per 10,000 person-years that were prevented in the CT-screening group when compared to the radiography group increased with risk quintile (0.2 in quintile 1, 3.5 in quintile 2, 1in quintile 3, 11.0 in quintile 4, and 12.0 in quintile 5; P=0.01 for trend). There were decreasing trends in the number of false positive results per screening-prevented lung-cancer death (1648 in quintile 1, 181 in quintile 2, 147 in quintile 3, 64 in quintile 4, and 65 in quintile 5). Subjects with the highest risk for lung-cancer death (quintiles 3 through 5) accounted for 88% of the screening-prevented lung-cancer deaths and for 64% of participants with false positive results. The 20% of participants at lowest risk (quintile 1) accounted for only 1% of prevented lung-cancer deaths. The authors concluded that "Screening with low-dose CT prevented the greatest number of deaths from lung cancer among participants who were at highest risk and prevented very few deaths among those at lowest risk."
A 2017 study by Rampinelli et.al. reported on the cumulative radiation exposure and lifetime attributable risk of cancer in those scanned with low-dose CT scans. In this retrospective review, 5203 asymptomatic, high-risk participants underwent annual low-dose CT scan for 10 consecutive years. High-risk status was defined as age greater than 50 years old, smoking history with greater than or equal to 20 pack-years, and no history of cancer in the past 5 years. The numbers of additional cancers cases induced by 10 years of screening was 1.5 lung cancers and 2.4 major cancers, an additional risk of induced major cancers of 0.05% (2.4/5,203). The authors concluded, "Radiation exposure and cancer risk from low dose CT screening for lung cancer, even if non-negligible, can be considered acceptable in light of the substantial mortality reduction associated with screening."
Based on review of the peer reviewed medical literature to include randomized controlled trials and prospective and retrospective studies of screening with chest radiography and/or low dose computerized tomography (LDCT) demonstrates that chest radiograph screening does not reduce mortality from lung cancer and that LDCT screening is significantly more sensitive than chest radiography for identifying small asymptomatic lung cancers in high risk individuals. The largest randomized controlled trial (RCT), the National Lung Screening Trial (NLST) was a multicenter trial published in 2011. This was a high quality trial that reported a decrease in both lung cancer mortality and overall mortality in a high risk population screened with 3 annual low dose CT scans compared with chest radiographs. A study in 2013 by Kovalchik et. al. investigated whether the benefits and harms of low-dose CT screening in the NLST participants differed according to the participants' prescreening risk of lung cancer death. The authors concluded that screening with low-dose CT prevented the greatest number of deaths from lung cancer among participants who were at highest risk and prevented very few deaths among those at lowest risk. There is considerable uncertainty regarding the optimal length and interval screening. Society guidelines recommend annual screening, and that 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. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcomes for those individuals at high risk for lung cancer. Therefore, screening for lung cancer with low dose computed tomography(LDCT) annually may be considered medically necessary for high risk patients who meet criteria and investigational otherwise.
Practice Guidelines and Position Statements
U.S. Preventative Services Task Force (USPSTF)
December 2013, the USPSTF recommended annual screening for lung cancer with low dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 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 surger.
A rating of A and B from the USPSTF applies to the Affordable Care Act (ACA) preventative services. This recommendation is Grade B.
National Comprehensive Cancer Network (NCCN)
Lung Cancer Screening (Version 3.2018)
Individuals with High Risk Factors
The NCCN Panel recommends lung cancer screening using LDCT for individuals with high risk factors. There are 2 groups of individuals who qualify as high risk:
- Group 1: Individuals age 55 to 74 years with a 30 or more pack year history of smoking tobacco who currently smoke, or if former smoker, have quit within 15 years (category 1). Initial screening with LDCT is category 1 recommendation for group 1, because these individuals are selected based on the NLST inclusion criteria. An NCCN category 1 recommendation is based on high level evidence (e.g. randomized controlled trial) and uniform consensus among panel members. Annual screening LDCT is recommended for these individuals with high risk factors based on the NLST. Annual screening LDCT is also recommended for those at high risk with negative LDCT scans or for those whose nodules do not meet the size cutoff for more frequent scanning or other intervention until individuals are no longer candidates for definitive treatment. Uncertainty exists about the appropriate duration of screening and the age at which screening is no longer appropriate.
- Group 2: Individuals age 50 years or older with a 20 or more pack-year history of smoking tobacco and with one additional risk factor (category 2A). Panel members expanded screening beyond the NLST criteria to a larger group of individuals at risk for lung cancer, which is described in greater detail in this section. LDCT screening is a category 2A recommendation for group 2 based on lower level evidence (e.g. nonrandomized studies, observational data, ongoing randomization trials). These additional risk factors were previously described and include personal history of lung cancer, radon exposure, and occupational exposure to carcinogens. Note that the NCCN Panel does not currently believe that exposure to second hand smoke is an independent risk factor, because the data are either weak or variable.
Individuals with Moderate Risk Factors
- NCCN defines individuals with moderate risk factors as those aged 50 years or older and with 20 or more pack year history of smoking tobacco or second hand smoke exposure but no additional lung cancer risk factors. The NCCN Panel does not recommend lung cancer screening for these individuals at moderate risk for lung cancer. This is a category 2A recommendation based on nonrandomized studies and observational data. Of interest, data show that some patients in the moderate risk group would benefit from lung cancer screening.
Individuals with Low Risk Factors
- NCCN defines individuals with low risk factors as those younger than 50 years and/or with a smoking history of fewer than 20 pack years. The NCCN Panel does not recommend lung cancer screening for these individuals at low risk for lung cancer. This is a category 2A recommendation based on nonrandomized studies and observational data.
American Cancer Society (ACS)
In 2013, the American Cancer Society (ACS) published guidelines on lung cancer screening with low dose CT. The guidelines recommend doctors initiate a discussion about lung cancer screening with people who meet criteria that put them at risk for developing the disease. These high risk patients must be:
- Aged 55 to 74 years and in fairly good health
- Have a smoking history equivalent to a pack a day for 30 years, and
- Currently smoking or have quit within the past 15 years
For patients who meet the above criteria and choose screening, screening is recommended annually until age 74 for individuals who otherwise remain healthy. In addition, the ACS recommends that adults who choose to undergo lung screening preferably should enter an organized screening program at an institution with expertise in LDCT screening, with access to a multidisciplinary team skilled in the evaluation, diagnosis, and treatment of abnormal lung lesions.
American College of Chest Physicians (ACCP)
In 2018, the American College of Chest Physicians (ACCP) updated their guidelines for screening for lung cancer, which includes the following recommendations:
- For asymptomatic smokers and former smokers 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 suggest that annual screening with low dose CT should be offered.
- Asymptomatic refers to the absence of symptoms suggesting the presence of lung cancer.
- For asymptomatic smokers and former smokers who do not meet the smoking and age criteria in the above recommendation but are deemed to be a high risk of having/developing lung cancer based on clinical risk prediction calculators, we suggest that low dose CT screening should not be routinely performed.
- For individuals who have accumulated fewer than 30 pack years of smoking or are younger than age 55 or older than 77, or have quit smoking more than 15 years ago, and do not have a high risk of having/developing lung cancer based on clinical risk prediction calculators, we recommend that low dose CT screening should not be performed.
- For individuals with comorbidities that adversely influence their ability to tolerate the evaluation of screen detected findings, or tolerate treatment of an early stage screen detected lung cancer, or that substantially limit their life expectancy, we recommend that low dose CT screening should not be performed.
American Association for Thoracic Surgery
In 2012, the American Association for the Thoracic Surgery published guidelines for lung cancer screening. The guidelines recommend annual lung cancer screening with low dose computed tomography (LDCT) for the following individuals:
- Age 55 to79 years
- With ≥ 30 pack year smoking history
Also, low dose computed tomography lung cancer screening should be offered at 50 to 79 years with a 20 pack year smoking history and additional comorgidity that produces cummulative risk of developing lung cancer of ≥5% in 5 years.
American Lung Association
The American Lung Association recomments lung cancer screening for high risk individuals that meet the following criteria:
- 55-80 years of age
- Have a 30 pack year history of smoking (this means 1 pack per day for 30 years, 2 packs per day for 15 years, etc.); AND
- Are a current smoker or have quit within the last 15 years
At this time, there is not enough evidence to show that screening is recommended for other groups.
This policy does not apply to individuals with signs and/or symptoms of lung disease. In symptomatic individuals, a diagnostic work up appropriate to the clinical presentation should be undertaken, rather than screening.
Low-dose computed tomography (LDCT) scanning, no more frequently than annually, may be considered medically necessary as a screening technique for lung cancer in asymptomatic individuals who meet ALL of the following criteria:*
- Individuals 55 through 80 years of age; and
- Have a 30 pack-year smoking history; and
- Currently smoke or have quit within the past 15 years
*Patient selection criteria is based on U.S. Preventative Services Task Force (USPSTF) B recommendation.
Lung cancer screening using low dose computed tomography (LDCT) would be considered not medically necessary for the following indications:
- Once the patient has not smoked for 15 years;
- A patient develops a health problem that substantially limits life expectancy;
- The patient is unwilling to have curative lung surgery.
Low-dose computed tomography (LDCT) is considered investigational as a screening technique for lung cancer when the above criteria is not met and for all other screening indications in asymptomatic individuals.
The incidence of lung cancer is relatively low in persons younger than 50 years of age. In current and former smokers the incidence rates increase with age and cumulative exposure to tobacco smoke. A study completed in 2013 by Kovalchik et. al. investigated whether the benefits and harms of low-dose CT screening in the NLST participants differed according to the participants' prescreening risk of lung cancer death. The authors concluded that screening with low-dose CT prevented the greatest number of deaths from lung cancer among participants who were at highest risk and prevented very few deaths among those at lowest risk. At this time the evidence is insufficient to show that screening would be beneficial or would outweigh the harms associated with screening for asymptomatic individuals considered at low to moderate risk for lung cancer. The evidence is insufficient to determine the effects on net health outcomes for asymptomatic individuals that do not meet high risk screening criteria above.
A pack-year is a way to measure the amount a person has smoked over a long period of time. It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked. For example, 1 pack year is equal to smoking 1 pack per day for 1 year, or 2 packs per day for half a year, and so on.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- G0297 Low dose CT scan (LDCT) for lung cancer screening
- Mahadevia PJ, Fleisher LA, Frick KD, Eng J, Goodman SN, Powe NR. Lung cancer screening with helical computed tomography in older adult smokers. A decision and cost effective analysis. JAMA 2002;289(3)313-322.
- Gohagan J, Marcus P, Fagerstrom R, Pinsky P, Kramer B, Prorok P; Writing Committee, Lung Screening Study Research Group. Baseline findings of a randomized feasibility trial of lung cancer screening with spiral CT scan vs chest radiograph: the Lung Screening Study of the National Cancer Institute. Chest. 2004 Jul;126(1):114-21.
- Institute for Clinical Systems Improvement (ICSI). Computed tomography screening for lung cancer. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); February 2001. ICSI Technology Assessment Report #52.
- ECRI. Computed tomography for lung cancer screening. Plymouth Meeting (PA): ECRI Health Technology Assessment Information Service; 2005 Jan. (Health Technology Forecast Report).
- ECRI. Helical computed tomography (CT) for lung cancer screening. Plymouth Meeting (PA): ECRI Health Technology Assessment Information Service; 2004 July. . TARGET [database online].
- Swensen SJ, Jett JR, Hartmen TE et al. CT screening for lung cancer: five-year prospective experience. Radiology. 2005 Apr;235(1):259-65.
- Henschke CI, Yankelevitz DF, Miettinen OS. Computed Tomographic Screening for Lung Cancer: The Relationship of Disease Stage to Tumor Size. Arch Intern Med 2006; 166:321-25.
- Lindell RM, Hartman TE, Swensen SJ et al. Five-year Lung Cancer Screening Experience: CT Appearance, Growth Rate, Location, and Histologic Features of 61 Lung Cancers. Radiology. 2007 Feb;242(2):555-62.
- The Early Lung Cancer Action Program Investigators. Survival of Patients with Stage I Lung Cancer Detected on CT Screening. N Engl J Med. 2006;355:1763-1771.
- Bach PB, Jett JR, Pastorino U et al. Computed Tomography Screening and Lung Cancer Outcomes. JAMA. 2007;297:953-961.
- Black C, de Verteuil R, Walker S, Ayres J, Boland A, Bagust A, Waugh N. Population screening for lung cancer using computed tomography, is there evidence of clinical effectiveness? A systematic review of the literature. Thorax, 2007 Feb;62(2):131-8.
- American Society of Clinical Oncology (ASCO) 45th Annual Meeting: Abstract CRA 1502. Presented May 30, 2009.
- Bach PB, Silvestri GA, Hanger M et al. Screening for Lung Cancer. ACCP Evidence-based clinical practice guidelines (2nd edition). Chest. 2007 Sep; 132 (3 Suppl) 69S-77S.
- Hocking WG, Oken MM, Winslow SD et al. Lung cancer screening in the randomized prostate, lung, colorectal and ovarian (PLCO) cancer screening trial. J Natl Cancer Inst 2010; 102(10):722-31.
- van Klaveren RJ Oudkerk M, Prokop M et al. Management of lung nodules detected by volume CT screening. N Engl J Med 2009; 361(23):2221-9.
- Croswell JM, Baker SG, Marcus PM et al. Cumulative incidence of false-positive test results in lung cancer screening. Ann Intern Med 2010; 152(8):505-12.
- National Lung Cancer Screening Trial Research Team; Aberle DR, Adams AM, Berg CD et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011; 365(5):395-409.
- van den Bergh KA, Essink-Bot ML, Borsboom GJ et al. Long-term effects of lung cancer computed tomography screening on health-related quality of life: the NELSON study. Eur Respir J 2011; 38(1):154-61.
- American Cancer Society Lung Cancer (non-small cell). Last revised July, 2011. Last accessed September 2011.
- ECRI Institute Professional societies endorse low-dose CT scans for lung cancer screening in high-risk patients. Plymouth Meeting (PA): ECRI Health Technology Assessment InformationService; 2012 August 1. [Health Technology Trends].
- Bach PB, Mirkin JN, Oliver TK, et al. Benefits and harms of CT screening for lung cancer: a systematic review. JAMA. 2012 Jun 13;307(22):2418-29.
- Saghir Z, Dirksen A, Ashraf H, et al. CT screening for lung cancer brings forward early disease. The randomized Danish Lung Cancer Screening Trial: status after five annual screening rounds with low-dose CT. Thorax. 2012 Apr;67(4):296-301.
- U.S. Preventative Services Tesk Force (USPSTF) Screening for Lung Cancer Recommendation Statement.
- National Comprehensive Cancer Network (NCCN), Lung Cancer Screening Version 1.2014.
- American Cancer Society New Lung Cancer Screening Guidelines for Heavy Smokers, January 11, 2013.
- National Cancer Institute National Lung Screening Trial (NLST), NCI Press Release, NIH Funded Study Shows 20 Percent Reduction in Lung Cancer Mortality with Low Dose CT Compared to Chest X-Ray.
- American Association for Thoracic Surgery Guidelines for Lung Cancer Screening Using Low Dose Computed Tomography Scans for Lung Cancer Survivors and Other High Risk Groups, Michael T. Jaklitsch, M.D. et al. The Journal of Thoracic and Cardiovascular Surgery, Volume 144, Number 1. July 2012. PMID 22710039
- The American Society of Clinical Oncology (ASCO), The Role of CT Screening for Lung Cancer in Clinical Practice. The Evidence Based Practice Guideline of the American College of Chest Physicians and the American Society for Clinical Oncology. Peter B. Back, M.D., et al. May 2012.
- UpToDate Screening for Lung Cancer. Mark E. Deffebach, M.D., Linda Humphrey, M.D. Topic last updated March 11, 2014.
- Peter B. Bach M.D., MAPP; Joshua N. Mirkin BA. Et. al. Benefits and Harms of CT Screening for Lung Cancer; A Systemic Review. JAMA May 20, 2012, Vol 307, No 22
- National Comprehensive Cancer Network (NCCN) Lung Cancer Screening Version 1.2015.
- American Lung Association Providing Guidance on Lung Cancer Screening to Patients and Physicians, April 23, 2012.
- UpToDate Screening for Lung Cancer, Mark E. Deffebach, M.D., Linda Humphrey, M.D.. Topic last updated November 9, 2017.
- ECRI Health Technology Forecast Computed Tomography with Computer-Aided Detection for Lung Cancer Screening. Published December 2013, Updated February 2015.
- National Comprehensive Cancer Network (NCCN) Lung Cancer Screening Version 3.2018.
- American Academy of Family Physicianst Lung cancer clinical recommendations.
- Centers for Medicare and Medicaid Services National Coverage Determination (NCD) 2010.14 Lung Cancer Screening with Low Dose Computed Tomography (LDCT).
- National Cancer Institute Lung Cancer Screening PDQ.
- Detterback F, Mazzone P, Naidich D, Back P. Screening for Lung Cancer – Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2013;14395)(Suppl):e78S-e92S
- Bach PB, Mirkin JN, Oliver TK, et. al. Benefits and harms of CT screening for lung cancer: a systematic review. JAMA 2012 Jun 13;307(22):2418-29
- California Technology Assessment Forum (CTAF). Low Dose Spiral Computerized Tomography (LDSCT) Screening for Lung Cancer. Technology Assessment October 19, 2011.
- Saghir Z, Dirksen A, Ashraf H, et. al. CT screening for lung cancer brings forward early disease. The randomized Danish Lung Cancer Screening Trial: status after five annual screening rounds with low dose CT. Thorax 2012 Apr;67(4):296-301
- American Thoracic Society/American College of Chest Physicians. An official American Thoracic Society/American College of Chest Physicians policy statement: Implementation of low dose computed tomography lung cancer screening programs in clinical practice.Am J Respir Crit Care Med 2015 Oct 1:192(7):881-91. PMID 26426785
- American College of Chest Physicians. Diagnosis and Management of Lung Cancer 3rd ed. American College of Chest Physicians Evidence Based Clinical Practice Guidelines, Screening for Lung Cancer. Chest 2013;143(5)(Suppl):e78S-e92S
- American College of Radiology (ACR)/Society of Thoracic Radiology (STR) Practice parameters for the performance and reporting of lung cancer screening thoracic computed tomography (CT) 2014.
- Centers for Disease Control (CDC) Lung Cancer.
- UpToDate. Preventative Care in Adults: Recommendations. H Nancy Sokol M.D., Topic last updated May 4, 2016.
- Humphrey LL, Deffebach M, Pappas M. et. al. Screening for lung cancer with low dose computed tomography: a systematic review to update the US Preventative Services Task Force recommendation. Ann Intern Med 2013 Sep 17;159(6):411-20. PMID 23897166
- Manser R. Lethaby A, Irving LB, et. al. Screening for lung cancer. Cochrane Database Syst Rev 2013 Jun 21;(6):CD001991. PMID 23794187
- Gould M. Lung cancer screening with low dose computed tomography. N Engl J Med 2014;371:1813-20
- Mazzone P, Silvestri G, Patel S, et. al. Screening for Lung Cancer: CHEST Guideline and Expert Panel Report. CHEST 2018.01.016
- Kovalchik S, Tammemagi M, Berg C, et.al. Targeting of Low Dose CT Scanning According to the Risk of Lung-Cancer Death. N Engl J Med 2013;369:245-54
- Rampinelli C, De Marco P, Origgi D, et. al. Exposure to low dose computed tomography for lung cancer screening and risk of cancer: secondary analysis of trial data and risk-benefit analysis. BMJ 2017;356:j347
- February 2018 - Annual Review, Policy Revised
- February 2017 - Annual Review, Policy Revised
- February 2016 - Annual Review, Policy Renewed
- March 2015 - Annual Review, Policy Revised
- April 2014 - Reinstated, Policy Revised
- April 2013 - Interim Review, Policy Retired
- September 2012 - Annual Review, Policy Renewed
- September 2011 - Annual Review, Policy Revised
- October 2010 - Annual Review, Policy Renewed
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