Local coverage determination (LCD) reconsideration process

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Home ► Coverage resources ► Local coverage determination (LCD) reconsideration process

Last Modified: 10/16/2024 Location: FL, PR, USVI Business: Part A, Part B

The 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 entire LCD or any provision of the LCD may be reconsidered.

Review our LCD reconsideration request process flowchart pdf file

LCDs are developed to convey under what circumstances an item/service is considered to be reasonable and necessary. We will consider reasonable and necessary services for payment in the absence of an LCD, billing and coding article, NCD, or CMS manual instruction limiting coverage.

All LCDs must be based on evidence. Please read our guidance on the strength of medical literature/evidence pdf file

that may be submitted for consideration.

1. LCD reconsideration requests will be considered from:

• Beneficiaries residing or receiving care in First Coast’s jurisdiction N (JN);

• Health care professionals 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 pdf file

• 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; and

• Any instance in which no LCD exists, e.g., 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 pdf file

. *If you need further assistance regarding NCD requests, please email NCDRequest@cms.hhs.gov.

3. How to submit a request:

First Coast LCDs apply to all states within our JN contracts; therefore, only one request needs to be submitted to encompass the jurisdiction. 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: 717-526-6389. Please note on your fax cover sheet “Attention: Medical Affairs – LCD Reconsideration Request – [LCD number and title]”.

• By U.S. postal service:

Office of the Contractor Medical Director
First Coast Service Options
Medical Affairs Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050

4. After a reconsideration 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 and 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 pdf file

Section 13.3.

• 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 is an acknowledgement only of the receipt and acceptance of a valid request.

• The request then goes on our waitlist to undergo our internal prioritization process which includes review of literature submitted. This process can take up to 12 months or more to complete. Topics are prioritized based on claims data, including how often a service is billed and the frequency a service is being denied. Access to care as well as associated quality health outcomes are also considered.

• Our website will be used to notify requestors and potentially interested parties of LCD revisions. If a requested LCD revision needs to be taken to our Contractor Advisory Committee (CAC) for evidentiary review we will publish notice of the CAC meeting to our website. If it is determined that a CAC meeting is not required, the revision will be posted for open comment and presented at an Open Meeting. When a proposed LCD is posted for open comment period, we will publish notice of the proposed LCD and Open meeting.

Source: CMS IOM Publication 100-08, PIM, Chapter 13, external pdf file

Section 13.3.2

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