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Last Modified: 9/10/2020 Location: FL, PR, USVI Business: Part A, Part B

Local coverage determination (LCD) reconsideration process

The local coverage determination reconsideration process is a mechanism for interested parties to request a revision to an LCD. The process is available only for final effective LCDs. The whole LCD or any provision of the LCD may be reconsidered.
1. LCD reconsideration requests will be considered from:
Beneficiaries residing or receiving care in First Coast’s jurisdiction.
Providers doing business in First Coast’s jurisdiction.
Any interested party doing business in First Coast’s jurisdiction.
2. Valid LCD reconsideration request requirements:
LCD reconsideration requests must be submitted in writing and must identify the language that the requestor wants added to or deleted from an LCD.
Requests must include a justification for the proposed change supported by new evidence not already listed in the LCD’s Sources of Information/Bibliography, which may materially affect the LCD’s content or basis. Electronic copies of literature are preferred. Medical literature must be published, include the full text (not abstracts), and be in English. 
The level of evidence required for an LCD reconsideration is the same as that required for a new/revised LCD development as per the Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM), Publication 100-08, Medicare Program Integrity Manual (PIM), Chapter 13, Section 13.2 external link.
Requests will not be accepted for other documents, including:
National coverage determinations (NCDs)
Coverage provisions in interpretive manuals
Proposed LCDs
Template LCDs, unless or until they are adopted by First Coast
Retired LCDs
Individual claim determinations
Bulletins, articles, or training materials
Any instance in which no LCD exists (i.e., requests for development of an LCD). Please refer to our new LCD request process for this type of request.
NOTE: If modification of the LCD would conflict with an NCD, the request is not valid. To request a revision to an NCD, please refer to the NCD determination process external link.
For more information on submitting a request for an NCD review, please see the August 7, 2013 Federal Register notice external link.
If you need further assistance regarding NCD requests, please email NCDRequest@cms.hhs.gov

How to submit a request

First Coast LCDs apply to jurisdiction N (Florida, Puerto Rico, U.S. Virgin Islands). LCD reconsideration requests may be sent via one of the three methods below:
By email:
Electronic requests should be sent to medicalaffairs@guidewellsource.com with “LCD Reconsideration Request – [LCD number and title]” in the subject line.
If the attachment size for clinical citations exceeds 10MB, the requestor must send the valid articles and supporting documents via multiple, smaller e-mails. Please contact medicalaffairs@guidewellsource.com for alternative methods for submitting large electronic files or if you have difficulty submitting an LCD reconsideration request.
By fax:
Requests should be faxed to 1 (717) 526-6389. Please notate on your fax cover sheet “Attention: Medical Affairs – LCD Reconsideration Request – [LCD number and title]”.
By U.S. postal service:
First Coast Service Options
Medical Affairs
2020 Technology Parkway
Suite 100
Mechanicsburg, PA 17050-9419

After a request is received

Within 60 calendar days of the date the request is received, First Coast will determine if the request is valid or invalid:
Any request for LCD reconsideration that, in the judgment of First Coast, does not meet the criteria described above, is invalid. If the request is invalid, First Coast will respond, in writing, to the requestor explaining why the request was invalid.
If the request is valid, First Coast will notify the requestor of the acceptance of the valid LCD reconsideration request. First Coast will consolidate valid requests, if similar requests are received.
A valid request does not convey that a determination has been made whether or not the item or service will be covered or non-covered under 1862 (a)(1)(A) of the act. The response to the requestor that the request is complete is an acknowledgement to the requestor of the receipt of a complete request.
If the request is valid, First Coast will follow the process for LCD reconsiderations detailed in the Centers for Medicare & Medicaid Services (CMS) Program Integrity Manual (Internet-only manual 100-08), Chapter 13 external link.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.