LCD Reference Article Article

Local Coverage Determination (LCD) Reconsideration Process - Medical Policy Article

A52842

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
NOT AN LCD REFERENCE ARTICLE
This article is not in direct support of an LCD.

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General Information

Source Article ID
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Article ID
A52842
Original ICD-9 Article ID
Not Applicable
Article Title
Local Coverage Determination (LCD) Reconsideration Process - Medical Policy Article
Article Type
Article
Original Effective Date
10/01/2015
Revision Effective Date
01/01/2024
Revision Ending Date
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Retirement Date
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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

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CMS National Coverage Policy

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Article Guidance

Article Text

The requirements in this article are based on instructions found in CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.3.1, 13.3.2 and 13.3.3. 

Reconsideration Request Process

The LCD reconsideration process is a mechanism by which a beneficiary or stakeholder (including a medical professional society or physician) in NGS jurisdiction can request a revision to an LCD. The LCD reconsideration process differs from an initial request for an LCD in that it is available only for final, effective LCDs. The whole LCD or any provision of the LCD may be reconsidered.

Reconsideration Requests May Be Submitted By National Government Services will consider all LCD reconsideration requests from:

  • Beneficiaries residing or receiving care in [our] jurisdiction (Alaska, American Samoa, Arizona, California, Connecticut, Guam, Hawaii, Illinois, Idaho, Maine, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, New York, Northern Mariana Islands, Oregon, Puerto Rico, Rhode Island, Vermont, U. S. Virgin Islands, Virginia, Washington, West Virginia and Wisconsin);
  • Providers doing business in [our] jurisdiction
  • Any interested party doing business in [our] jurisdiction.

Acceptable Requests The LCD Reconsideration Process is available only for final, effective LCDs. The whole LCD or any provision of the LCD may be reconsidered.

Unacceptable Requests

Requests are not accepted for other documents including:

  • National Coverage Determinations (NCDs)
  • Coverage provisions in interpretive manuals
  • Proposed LCDs;
  • Template LCDs, unless or until they are adopted and in effect by the contractor;
  • Retired LCDs;
  • Individual claim determinations;
  • Bulletins, articles, training materials; and
  • Any instance in which no LCD exists, i.e, requests for development of an LCD.

Submission Documentation Requirements

Requests must be submitted in writing and include the following items:

· name and address of beneficiary or provider; or

  • if the requestor is neither a beneficiary, nor a provider, the name and address of the organization he/she represents and the nature of that organization's business
  • e-mail address (preferred);
  • telephone number (optional)
  • the name of the final, effective LCD, and
  • copies of published evidence, and
  • language wanted to be added to or deleted from the LCD.

Health Disparities Analysis (Recommended)

Requestors are strongly encouraged to include an analysis of any relevant peer-reviewed medical literature that quantifies and/or describes any health disparities related to the specific LCD Reconsideration request, and how the requested change may impact health disparities.

Submission Methods Mail

National Government Services, Inc. Medical Policy Unit Attention: LCD Reconsideration Request P.O. Box 7108 Indianapolis, IN 46207-7108

E-Mail

NGS.lcd.reconsideration@anthem.com

Fax (317) 595-4334

National Government Services Response Within 60 days of the day the request is received, National Government Services will determine whether the request is valid or invalid and will notify the requestor of the determination.

Valid Request Possible Actions

If the request is valid, NGS will either open the LCD and follow the LCD process as outlined in CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.2, or include the LCD on the MAC’s waiting list.

Invalid Request Action

If the request is invalid, NGS will explain the reason(s) it was invalid.

 

Response To Comments

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Coding Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2024 R7

Updated to indicate the article is not an LCD Reference Article

01/01/2024 R6

The following language was added to the Article Text section: 

Health Disparities Analysis (Recommended)

Requestors are strongly encouraged to include an analysis of any relevant peer-reviewed medical literature that quantifies and/or describes any health disparities related to the specific LCD Reconsideration request, and how the requested change may impact health disparities.

01/01/2019 R5

Based on CR10901, the Reconsideration Process has been revised.

01/15/2018 R4

Removed contact name for submission of LCD reconsideration requests.

01/15/2018 R3

Updated the fax number for LCD reconsideration requests.

01/15/2016 R2 Updated the fax number for LCD reconsideration requests.
10/01/2015 R1 Removed CPC credentials.

Added a clarification that scientific data or research studies published in peer-reviewed medical journals must be indexed on PubMed (from the US National Library of Medicine, National Institute of Health).

Removed the telephone number for the Provider Outreach and Education Department. Reformatted items under the ?"Information to be Submitted"? section to be consistent with the Medicare Program Integrity Manual.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
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Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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CMS Manual Explanations URLs
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Public Versions
Updated On Effective Dates Status
11/17/2023 01/01/2024 - N/A Currently in Effect You are here
11/15/2023 01/01/2024 - N/A Superseded View
12/18/2018 01/01/2019 - 12/31/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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