LCD Reconsideration Process


The Local Coverage Determination (LCD) Reconsideration process is a method by which interested parties can request a revision to an active LCD. Palmetto GBA follows the Centers for Medicare & Medicaid Services (CMS) Program Integrity Manual (Internet-Only Manual 100-08), Chapter 13 process for LCD Reconsiderations. The reconsideration process is available for final, effective LCDs only. The entire LCD or any part of it is subject to reconsideration. The process for LCD Reconsideration is outlined below.
 

Informal Meeting (Optional)
Prior to submitting a formal LCD Reconsideration, Palmetto GBA encourages requestors to schedule an informal meeting to review the requirements for a valid request.

Request for a conference call may be submitted via email to A.Policy@palmettogba.com, B.Policy@palmettogba.com or MolDX.Policy@palmettogba.com. The request should include the following information:

  1. Subject line of the email should state: "Request for Informal Meeting — [Title/LCD ID#]"
  2. Several dates and times the requestor is available for a 30 minute call
  3. Agenda for the call, including requestor, participants, and titles
  4. Summary information (1–2 paragraphs, maximum) for the reconsideration request
     

Reconsideration Request Submission Criteria
Reconsideration requests are only accepted for LCDs published in final form. Requests will not be accepted for other documents including:

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

Palmetto GBA has the discretion to consolidate valid requests if similar requests are received. Any request for LCD reconsideration that, in the judgment of the contractor, does not meet these criteria is invalid.

Palmetto GBA may revise or retire LCDs at its descretion.

If modification of the final LCD would conflict with an NCD, the request will not be valid. For information about the NCD reconsideration process, reference http://www.cms.gov/DeterminationProcess/01_overview.asp#regs. Information about requesting an NCD or an NCD revision is found under "How to Request an NCD" in the Coverage Process section.

A valid request must include:

  1. The specific language that the requestor proposes added to or deleted from an LCD; and
  2. Justification for the proposed change supported by new evidence in the medical literature which will materially affect the LCD's content or basis. Electronic copies of published (i.e., not embargoed), English language, full-text articles are required. The level of evidence required for LCD reconsideration is the same as that required for new or revised LCD development (see Program Integrity Manual, Chapter 13).
     

How to Submit Request
LCD reconsideration requests may be submitted via email to A.Policy@palmettogba.com, B.Policy@palmettogba.com or MolDX.Policy@palmettogba.com. The subject line of the email should state: "Request for LCD Reconsideration Request — [Title/LCD ID#]."

Please note that this information is for Palmetto GBA LCD reconsiderations only. Information for submitting an LCD reconsideration request for other jurisdictions may be found on their websites.
 

Next Steps
Palmetto GBA will review materials received within 60 calendar days upon receipt and determine whether the request is valid or invalid. If the request is invalid, Palmetto GBA will respond in writing to the requestor explaining why the request was invalid.

A valid request response does not convey that a determination has been made as to whether the item or service will be covered or non-covered; it  is simply an acknowledgement to the requestor of the receipt of a complete, valid request.

If the request is valid, Palmetto GBA will follow the process for LCD reconsiderations detailed in the Centers for Medicare & Medicaid Services (CMS) Program Integrity Manual (Internet-Only Manual 100-08), Chapter 13.

Once the submitted material is reviewed, the requestor will be contacted should the Palmetto GBA have additional questions. If there are no additional questions from Palmetto GBA, the requestor should monitor the Palmetto GBA websites and email updates for the posting of a proposed LCD, date and time for an open meeting, and a timeline for completion of the reconsideration request. This information can be found under the Medical Policies section of the Palmetto GBA website.

Related Information: Medicare Program Integrity Manual, Chapter 13 (PDF, 124 KB) — Local Coverage Determinations.





LCD Reconsideration Process Articles