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Last Modified: 4/21/2017 Location: FL, PR, USVI Business: Part A, Part B

Local coverage determination reconsideration process for the JN MAC

The "Local coverage determination (LCD) reconsideration process" is a process by which interested parties can request a revision to a JN 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 JN 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: medical.policy@fcso.com or the address listed below:
First Coast Service Options Inc.
ATTN: Medical Policy Department, LCD Reconsideration
P.O. Box 2078
Jacksonville, Florida 32231-0048
Please note that the LCD reconsideration process applies only to finalized, active, JN MAC Part A and/or Part B LCDs. These LCDs are posted on the contractor’s website. 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 https://www.cms.gov/Medicare/Coverage/DeterminationProcess/howtorequestanNCD.html 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.