LCD Reconsideration Process - JA DME
LCD Reconsideration Process
Note: This process is for the reconsideration of a local coverage determination (LCD), not individual claims. For more information about appealing individual claims, visit the Appeals webpages.
The Local Coverage Determination (LCD) Reconsideration process is a method by which interested parties may request a revision to an active LCD. Noridian 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 Teleconference (Optional)
Prior to submitting a formal LCD Reconsideration, the DME MACs encourage requestors to schedule an informal conference call to review the requirements for a valid LCD Reconsideration request. A request for a conference call may be submitted via email. In the request for an informal discussion, requestors should include the following information:
- Include in the subject line of the email: "Request for LCD Reconsideration Call - [Title of LCD]"
- Several options for dates and times for a one (1) hour conference call
- Teleconference number with enough lines to accommodate 15 participants
- Agenda for the call, including requestor participants and titles
- Summary information (1-2 paragraphs, maximum) for the reconsideration request.
Request Submission Criteria (Required)
Following the informal discussion, should the requestor wish to continue with a formal LCD Reconsideration request, a valid request must meet all of the following requirements:
Be submitted by one of the following:
- 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.
- Include the specific language that the requestor proposes added to or deleted from the LCD; and,
- Submission of all available evidence, as well as all related FDA approval correspondence, marketing designations, decision summaries pertinent to the product or service, 510(k)/PMA/De Novo notifications, SSED data sheet, FDA Panel Minutes and Post-Approval Study Result/Outcome Submissions. Submitted literature and references should be limited to published, full-text, peer-reviewed evidence, indexed in PubMed of the US National Library of Medicine, National Institutes of Health. The failure to include specific literature with the request will render the LCD request invalid.
Only request reconsideration of an LCD 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, unless or until they are adopted 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.
The level of evidence required for LCD reconsideration is the same as that required for new/revised LCD development (see Program Integrity Manual, Chapter 13).
Noridian 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.
Noridian may revise or retire their LCDs at any time on their own initiatives.
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 the Medicare Coverage Determination Process webpage. Information about requesting an NCD or an NCD revision is found under "How to Request an NCD" in the Coverage Process section.
How To Submit Request
LCD Reconsideration requests may be sent via one of three methods: email (preferred), fax or, hard copy by mail. Pertinent information for each of the three methods is listed below:
Email (Preferred Method)
- Electronic requests should be sent with "LCD Reconsideration Request - [Name of LCD]" in the subject line.
- If the attachment size for clinical citations exceeds 15 MB, the requestor must send the articles and supporting documents via multiple, smaller emails.
- Email us for alternative methods for submitting large electronic files or if you have difficulty submitting an LCD Reconsideration request.
- Please address your fax cover sheet to DME LCD Reconsideration - Attn: JA Medical Director.
- Note: This fax line is for the LCD reconsideration process described above. This is not the fax line for appealing individual claims (Redeterminations).
Note: This information is for DME MAC LCD reconsiderations only. Information for submitting an LCD reconsideration request for Jurisdiction E or F A/B MAC may be found at the JE or JF website.
Noridian will review the materials received to determine whether the request is valid. A valid request must meet criteria 1-4 listed above. Noridian will respond to the request within 60 calendar days upon receipt.
If Noridian determines that the request is not valid, Noridian will notify the requestor in writing that the request is not valid and will provide the rationale for this decision.
If the request is valid, Noridian will begin the LCD development process outlined in the Program Integrity Manual Chapter 13 (Internet-only Manual Pub.100-08). The response to the requestor is an acknowledgement by Noridian of the receipt of a valid, complete request. A request response from Noridian does not convey that a determination has been made or the likelihood of coverage, or non-coverage, within a defined period of time under 1862 (a)(1)(A) of the Act, but is confirmation that Noridian plans to proceed with reconsidering the LCD or place the requested LCD reconsideration on the wait-list for development at a later time.
If the request is valid and the LCD is accepted for reconsideration, Noridian will follow the process outlined in the Program Integrity Manual, Chapter 13. This involves:
- Consultation with the requestor or subject matter experts (if necessary);
- Contractor Advisory Committee (CAC) meeting (if necessary);
- Publication of a proposed LCD;
- Open meeting to solicit comments from the public on the proposed LCD;
- Opportunity for public comment in writing (minimum of 45 days following posting of proposed LCD);
Publication of a final LCD, including:
- A response to public comments received;
- Notice to public of the new policy at least 45 days in advance of the effective date.
Proposed LCDs will be finalized or retired within a rolling calendar year of publication date on the Medicare Coverage Database website (365 days).
Last Updated Wed, 05 Feb 2020 14:48:41 +0000