SUPERSEDED LCD Reference Article Article

New Local Coverage Determination (LCD) Request Process

A56198

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General Information

Source Article ID
N/A
Article ID
A56198
Original ICD-9 Article ID
Not Applicable
Article Title
New Local Coverage Determination (LCD) Request Process
Article Type
Article
Original Effective Date
01/01/2019
Revision Effective Date
01/01/2019
Revision Ending Date
12/31/2023
Retirement Date
N/A

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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 13.2, 13.2.2.2, 13.2.2.3, and 13.2.1.1.

New LCD Request Process

The New LCD Request Process is a mechanism by which interested parties within a contractor’s jurisdiction can request a new LCD. New LCD requests will be considered from:

  • Beneficiaries residing or receiving care in a contractor’s jurisdiction;
  • Health care professionals doing business in a contractor’s jurisdiction; and
  • Any interested party doing business in a contractor’s jurisdiction.

The materials received will be reviewed within 60 calendar days from receipt and a determination will be made as to whether the request is complete or incomplete.

Valid Request Criteria

  • The request is in writing and can be sent to the MAC via e-mail, facsimile or written letter;
  • The request clearly identifies the statutorily-defined Medicare benefit category to which the requestor believes the item or service falls under and provides a rationale justifying the assignment;
  • The request shall identify the language that the requestor wants in an LCD;
  • The request shall include a justification supported by peer- reviewed evidence. Full copies of published evidence to be considered shall be included and failure to include same invalidates the request;
  • The request shall include information that addresses the relevance, usefulness, clinical health outcomes, or the medical benefits of the item or service; and
  • The request shall include information that fully explains the design, purpose, and/or method, as appropriate, of using the item or service for which the request is made.

If the request is valid, NGS will follow the LCD process as outlined in CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.2 or notify the requestor why the request is invalid.

Requests for Informal Meeting

  • Informal meetings may be held, so that interested parties in the MAC’s jurisdiction can informally discuss ONLY potential LCD requests.
  • The meetings are for educational purposes only and are not pre-decisional negotiations.
  • These meetings are permitted but are not required and the process allows requestors to communicate via conference call or in-person meeting before submitting a formal request for a new LCD.
  • These meetings will ensure that all relevant evidence needed for review for coverage is submitted with the request for a formal review.
  • Requests for development of a new LCD, or for informal meetings should be submitted to the e-mail address below.

Submission Methods

E-Mail

NGSnewlcdrequest@anthem.com

Fax

(317) 595-4334

Attention: New LCD Request

Mail

National Government Services, Inc.

Medical Policy Unit

Attention: New LCD Request

P.O. Box 7108

Indianapolis, IN 46207-7108

 

Response To Comments

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Coding Information

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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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

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Group 1 Codes

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ICD-10-CM Codes that are Covered

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ICD-10-CM Codes that are Not Covered

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ICD-10-PCS Codes

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Additional ICD-10 Information

Bill Type Codes

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Revenue Codes

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Other Coding Information

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Coding Table Information

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Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2019 R1

Article revised to correct the fax number.

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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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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Public Versions
Updated On Effective Dates Status
11/18/2023 01/01/2024 - N/A Currently in Effect View
11/03/2023 01/01/2024 - N/A Superseded View
12/19/2018 01/01/2019 - 12/31/2023 Superseded You are here
12/04/2018 01/01/2019 - N/A Superseded View

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