Fact sheet

Summary of Significant Changes to the Medicare Program Integrity Manual Chapter 13 – Local Coverage Determinations

Summary of Significant Changes to the Medicare Program Integrity Manual Chapter 13 – Local Coverage Determinations

The Centers for Medicare & Medicaid Services (CMS) has revised chapter 13 of the Medicare Program Integrity Manual (PIM). This chapter describes the local coverage determinations (LCD) process. The revision was in response to a provision of the 21st Century Cures Act intended to improve transparency in the LCD process. The manual includes instructions, policies and procedures for Medicare Administrative Contractors (MACs) that administer the Medicare program in different regions of the country, as well as guidance for stakeholder engagement in the process. The revised manual includes:

  • Clear process “roadmap.” A step-by-step description of the LCD process in language that is accessible to all stakeholders.
     
  • Consistent presentation of evidence. Standardized summary of clinical evidence supporting LCD decisions and a MAC coverage determination rationale.
     
  • Informal meetings with MACs. Option to request an informal meeting with the MAC to discuss potential LCD requests.
     
  • New LCD request process. A novel process by which interested parties in a MAC jurisdiction can request a new LCD.
     
  • Restructured Contractor Advisory Committee (CAC) meetings. Meetings open to the public. CAC members serve in an advisory capacity as representatives of their constituency to review the quality of the evidence used in the development of an LCD. MACs can host CAC meetings in various ways (e.g., in-person, telephone, video, webinar). MACs determine how frequently these meetings occur based on the appropriateness and volume of LCDs requiring CAC input. 
     
  • More voices on CAC. In addition to physicians, other healthcare professionals (e.g., nurses, social workers, epidemiologists) can participate in the CAC. The CAC also must include beneficiary representation.
     
  • Repurposed public meetings. Open meetings in the MAC jurisdiction to present proposed coverage, including evidence and rationale of decisions. MACs clearly identify the location, dates and conference information (e.g., telephone, webinar) and distinguish these meetings from CAC meetings. 
     
  • No “old” proposed policies. Proposed policies retired if not finalized within 1 year of the original posting date.
     
  • Relocation of codes. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and Current Procedure Terminology (CPT) codes removed from LCD in the future.
     
  • Better communication. MAC responses to public comments linked to the final LCD and remain in the Medicare Coverage Database indefinitely (archives). MACs notify the public when they publish a final decision and provide a web link to it.
     
  • Consistent reconsideration process. LCD reconsideration process consistent with the National Coverage Determination reconsideration process. MACs must follow the full LCD process for valid requests.

For more information:
Medicare Program Integrity Manual (PIM) Chapter 13
Medicare Coverage Center
MAC Interactive Map

 

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