LCD Reconsideration Process

This process is for the reconsideration of a local coverage determination (LCD), not individual claims. Information on appealing individual claims through the claims redeterminations process may be found on the Appeals webpage.

The Local Coverage Determination (LCD) Reconsideration process is a method by which interested parties can request a revision to an active LCD. Noridian follows the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 13 process for LCD Reconsiderations. The reconsideration process is only available for final, effective LCDs. 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, Noridian encourages requestors to schedule an informal conference call to review the requirements for a valid LCD Reconsideration request. Request for a conference call are to be submitted via email.

In the request for an informal teleconference, requestors should include the following information:

  1. Include in the subject line of the email: "Request for LCD Reconsideration Call - [Title of LCD]"
  2. Several options for dates and times for a one (1) hour conference call
  3. Teleconference number with enough lines to accommodate 15 participants
  4. Agenda for the call, including requestor participants and titles
  5. Summary information (1-2 paragraphs, maximum) for the reconsideration request.

LCD Reconsideration Request Submission Criteria (Required)

Noridian will consider all LCD reconsideration requests from:

  • Beneficiaries residing or receiving care in our contractor's jurisdiction; and
  • Providers doing business in our contractor's jurisdiction.
  • Any interested party doing business in our contractor's jurisdiction

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

  • National coverage Decisions (NCD);
  • 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.

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. View information about the NCD reconsideration process. Information about requesting an NCD or an NCD revision is found under "How to Request an NCD" in the Coverage Process section.

Following the informal discussion, should the requestor wish to continue with a formal LCD Reconsideration request, 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 LCDs content or basis. Full-text copies (i.e., not abstracts, meeting poster presentations, manuscripts or embargoed documents) of published evidence from peer-reviewed scientific/medical literature must accompany the request.  Failure to include full-text clinical literature invalidates the request.

The level of evidence required for LCD reconsideration is the same as that required for new/revised LCD development (see CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 13

How to Submit an LCD Reconsideration Request

LCD Reconsideration requests may be sent via one of three methods: email (preferred), hard copy by mail, or fax. View the three methods below.

  1. Email (Preferred Method)
    • Electronic requests should be sent with "LCD Reconsideration Request – [Name of LCD]" in subject line
    • If attachment size for clinical citations exceeds 25 MB, requestor must send articles and supporting documents via multiple, smaller emails
    • Contact Krista Babbitt, 701-715-9440, for alternative methods for submitting large electronic files or if you have difficulty submitting an LCD Reconsideration request
  2. Fax
    • Address your fax cover sheet to Noridian LCD Reconsideration
    • Note: This fax line is only for the LCD reconsideration process described above. This is not the fax line for appealing individual claims (Redeterminations).
  3. Mail

NOTE: This information is for Noridian Part A and/or Part B LCD reconsiderations only. Information for submitting an LCD reconsideration request for Jurisdiction A or D DME MAC may be found at the JA or JD website.

Next Steps

Noridian will review materials received within 60 calendar days of receipt and determine whether the request is valid or invalid. If the request is invalid we 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 whether or not the item or service will be covered or non-covered under 1862 (a)(1)(A) of the Act. The response to the requestor that the request is valid is simply an acknowledgement to the requestor of the receipt of a complete, valid request.

If the request is valid, Noridian will follow the process for LCD Reconsiderations detailed in the CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 13. Once the submitted material is reviewed, you will be contacted should there be any additional questions. If there are no additional questions from Noridian, you should monitor the Noridian websites and listservs for the posting of a proposed LCD, date and time for a public meeting and timeline for completion of your reconsideration request. This information can be found under in the Local Coverage Determinations section of the website.

Noridian will post updates to the LCD Summary Sheet on the Medicare Coverage Database website. Final LCDs will be finalized or retired within a rolling calendar year of publication date on the Medicare Coverage Database (365 days).   

Related Information

 

Last Updated Mon, 18 Mar 2019 12:02:54 +0000