LCD Reconsideration Process
The Local Coverage Determinations (LCD) Reconsideration Process is a process by which interested parties can request a revision to a policy written by Medicare. We will gladly consider all requests for LCD reconsideration received from Medicare beneficiaries who receive care or reside in our Medicare jurisdiction, Medicare providers or interested parties doing business in our Medicare jurisdiction. We will, at our discretion, reconsider LCD's based on such requests.
Interested parties, utilizing the LCD Reconsideration Process, may request that we modify any section of an existing LCD. Requests for policy modification generally involve requests that information be added to a LCD or that information be deleted from an LCD. The entire LCD or any part of the LCLD may be reconsidered, i.e. Benefit Category Provision, Utilization Guidelines, Covered ICD-9 codes, etc.
The LCD Reconsideration Process is available only for final, active LCD's. Requests for reconsideration will not be made for:
- National Coverage Decisions (NCD);
- Coverage provisions in interpretive manuals;
- Draft LCD's;
- Template LCD's, unless or until they are adopted by the contractor;
- Retired LCD's;
- Individual claims determination;
- Bulletins, articles, training materials; and
- Any instance in which no LCD exists, i.e. request for development of an LCD.
If modification of the LCD would conflict with a NCD, the request would not be valid. Requests for modification of a NCD should be referred to CMS at www.cms.hhs.gov/DeterminationProcess/.
All requests must be submitted in writing, and shall clearly identify the specific language that the requestor wants added or deleted from a LCD. Requests shall include a justification supported by new evidence, which may materially affect the LCD's content or basis. Copies of published evidence shall be included with the request.
The level of evidence required for LCD reconsideration is the same as that required for new/revised LCD development. (PIM Chapter 13, Section 13.7.1)
Any request for LCD reconsideration that, in the judgement of the contractor, does not meet these criteria is invalid.
Contractors have the discretion to consolidate valid requests if similar requests are received.
Within 30 days of the receipt of the written request we will determine if the request is valid or invalid (i.e. conforms to the requirements as indicated above). If the request is invalid, we will respond, in writing, to the requestor explaining why the request was invalid. If the request is valid, we will, within 90 days of the day the request was received, make a final LCD reconsideration decision and notify the requestor of the decision along with the rationale for the decision. We may make the decision to:
- revise the policy to be more restrictive;
- revise the policy to be less restrictive;
- retire the policy; or
- make no revision to the policy
If the decision is to retire the LCD or to make no revision to the LCD, we will notify the requestor in writing of that decision with rationale.
If the decision is to revise the LCD, the normal process for LCD development will be followed.
Requests for LCD reconsideration should be mailed, faxed, or e-mailed to:
WPS Medicare
Attn: Medical Review Policy
P. O. Box 1602
Omaha, Nebraska 68101
Fax to: 402-351-5931 Attn: Medical Review Policy
Email: marie.krieger@wpsic.com or deb.wohlenhaus@wpsic.com
Page Last Updated: Tuesday, 15-Jul-2008 10:34:28 CDT
