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Last Modified: 3/8/2013
Location: FL, PR, USVI
Business: Part A, Part B
Local coverage determination reconsideration process for the J9 MAC
The "Local coverage determination (LCD) reconsideration process" is a process by which interested parties can request a revision to a J9 MAC LCD. First Coast Service Options Inc. (First Coast) will gladly consider all requests for LCD reconsideration received from Medicare beneficiaries who reside (or receive care) in Florida, Puerto Rico, or the U.S. Virgin Islands or from providers who do business in Florida, Puerto Rico, or the U.S. Virgin Islands. Additionally, First Coast will review requests received from other interested parties and, at its discretion, reconsider LCDs based on such requests.
Individuals utilizing the LCD reconsideration process can request that the contractor modify any section of an existing LCD. Generally, requests for policy modification will involve requests that information be added to an LCD or that information be deleted from an LCD. For example, one might request that changes be made to the "Indications and Limitations" section of an LCD, or one might request that additional diagnoses be added to the "Diagnoses that Support Medical Necessity" section of an LCD.
All LCD reconsideration requests must be submitted in writing and must clearly state the specific revisions/modifications that the requestor is seeking. Requests must include a justification supported by evidence, which may materially affect the LCD content or basis. Copies of published evidence (e.g., peer-reviewed medical literature, published studies, etc.) must be included with the revision request.
Once the contractor receives a written request for a LCD reconsideration, the contractor will, within 30 days, determine if the request is valid (i.e., satisfies the requirements outlined above). If the request is invalid, the contractor will respond in writing to the requestor explaining why the request was invalid. If the request is valid, the contractor will, within 90 days of the day the request was received, make a final LCD reconsideration decision and notify the requestor of the decision along with the rationale for the decision. Decisions made by the contractor may include one of the following:
• Retirement of the policy
• No revision of the policy
• Revision to a more restrictive policy
• Revision to a less restrictive policy
If the decision is either to retire the LCD, or to make no revision to the LCD, then within 90 days of the day the request was received, the J9 MAC will inform the requestor of its decision and the rationale for the decision. If the decision is to revise the LCD, the normal process for LCD development will be followed.
Requests for LCD reconsiderations should be sent to the following address, fax, or email:
First Coast Service Options Inc.
ATTN: Medical Policy Department, LCD Reconsideration
P.O. Box 2078
Jacksonville, Florida 32231-0048
ATTN: Medical Policy Department, LCD Reconsideration
P.O. Box 2078
Jacksonville, Florida 32231-0048
FAX: 904-791-8006
EMAIL: medical.policy@fcso.com
EMAIL: medical.policy@fcso.com
Please note that the LCD reconsideration process applies only to finalized, active, J9 MAC Part A and/or Part B LCDs. These LCDs are posted on the contractor’s Web site. The "LCD reconsideration process" does not apply to the following:
• National coverage decisions (NCD) – coverage provisions in the Medicare NCD Manual, Coverage Issue Manual, Federal Register, Code of Federal Regulations, etc.
• Draft LCDs
• Template LCDs
• Retired LCDs
• Individual claim determinations
• Bulletins, articles or training materials
• Any instance in which no LCD exists (for example, a request to develop a LCD)
Information concerning the process for requesting modification of a National Coverage Decision can be found at http://www.cms.gov/DeterminationProcess/01_Overview.asp 
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