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

Journey to LCD coverage

Click each step below to better understand how LCDs can work for you.
Understanding LCDs - link to step 1 Development process - link to step 2 Available resources - a link to step 3
Understanding LCDs

Step 1 - Understanding LCDs

Tips

How do I check to see if a service is covered?
Check if prior authorization is required
Use our Medical policy search tool for LCDs, Billing and Coding Articles, or National Coverage Determinations (NCDs)
Visit our LCD index to find active, future effective, proposed, and retired LCDs
Find information on clinical trials and devices
How do LCDs relate to processing claims?
If there is an applicable LCD for an item/service, follow the guidelines in the LCD and companion Billing and Coding Article when submitting claims
If no applicable LCD but there is an NCD external link, claims process according to the NCD
If a claim denies, you have the right to request a claim redetermination (appeal)
Why are LCDs developed or retired?
LCDs are developed to convey under what circumstances an item/service is considered to be reasonable and necessary
Visit our LCD development process to learn more about how and why LCDs are developed
Visit our LCD retirement process to understand why LCDs may be retired.
Development process

Step 2 - Development process

Tips

How can I be involved in the LCD development process?
Volunteer to become a CAC member and be involved in evidentiary review CAC meetings
If you don't want to be a CAC member, you can still participate in any open meeting and/or provide written comments on a proposed LCD
Keep us informed about a new drug, device, test, updated costs or indications using our submission of new drug information protocol
What if I want an LCD revised or a new LCD developed?
An LCD is not written to convey an item/service is covered, but can set coverage limitations or establish non-coverage of an item/service
If there is no active LCD for an item/service and you would like one developed, submit a request for a new LCD
If there is an active LCD that you would like revised, submit an LCD reconsideration request
All LCDs must be based on evidence. Please read our perspective on the strength of medical literature/evidence pdf file that may be submitted for consideration
I received confirmation my new LCD request or LCD reconsideration request is valid. Now what?
New LCD request topics and valid LCD reconsideration requests are waitlisted and undergo our internal prioritization process
At MAC discretion, a new LCD topic may go to an evidentiary review Contractor Advisory Committee (CAC) meeting
New and revised proposed LCDs undergo a 45-day public comment period and an open meeting
MACs are to finalize or retire all proposed LCDs within a rolling year of publication date of the proposed LCD on CMS' Medicare coverage database (MCD) (365 days)
Available resources

Step 3 - Find available resources

Tips

How do I find information about claims or appeals?
Visit our claims page for information on claim billing, coding, NCCI, MUE, submission, status, issues, rejections, or denials
Electronic billers can visit the Electronic billing - EDI page and SPOT portal
Visit our Appeals page for information on submitting a claim redetermination (appeal) or status of an appeal
Contact us if you have any questions
What educational opportunities are available?
Increase your knowledge of the Medicare program by participating in live and on-demand education by visiting our Learning center
Stay informed of LCD and other updates by subscribing to our email list
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.