Local Coverage Determination (LCD) Reconsideration Process - Medical Policy
Article

The requirements in this article are based on instructions found in CMS
Publication 100-08, _Medicare Program Integrity Manual_ , Chapter 13, Section
13.3.1, 13.3.2 and 13.3.3.

**Reconsideration Request Process**

The LCD reconsideration process is a mechanism by which a beneficiary or
stakeholder (including a medical professional society or physician) in NGS
jurisdiction can request a revision to an LCD. The LCD reconsideration process
differs from an initial request for an LCD in that it is available only for
**final, effective LCDs**. The whole LCD or any provision of the LCD may be
reconsidered.

**Reconsideration Requests May Be Submitted By** National Government Services
will consider all LCD reconsideration requests from:

  * _Beneficiaries residing or receiving care in_ [our] _jurisdiction_ (Alaska, American Samoa, Arizona, California, Connecticut, Guam, Hawaii, Illinois, Idaho, Maine, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, New York, Northern Mariana Islands, Oregon, Puerto Rico, Rhode Island, Vermont, U. S. Virgin Islands, Virginia, Washington, West Virginia and Wisconsin);
  * _Providers doing business in_ [our] _jurisdiction_
  * _Any interested party doing business in_ [our] _jurisdiction_.

**Acceptable Requests** _The LCD Reconsideration Process is available only for
final, effective LCDs. The whole LCD or any provision of the LCD may be
reconsidered._

**Unacceptable Requests**

Requests are not accepted for other documents including:

  * _National Coverage Determinations (NCDs)_
  * _Coverage provisions in interpretive manuals_
  * _Proposed LCDs;_
  * _Template LCDs, unless or until they are adopted_ _and in effect_ _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._

**Submission Documentation Requirements**

Requests must be submitted in writing and include the following items:

* name and address of beneficiary or provider; or

  * if the requestor is neither a beneficiary, nor a provider, the name and address of the organization he/she represents and the nature of that organization's business
  * e-mail address (preferred);
  * telephone number (optional)
  * the name of the final, effective LCD, and
  * copies of published evidence, and
  * language wanted to be added to or deleted from the LCD.

**Health Disparities Analysis (Recommended)**

Requestors are strongly encouraged to include an analysis of any relevant
peer-reviewed medical literature that quantifies and/or describes any health
disparities related to the specific LCD Reconsideration request, and how the
requested change may impact health disparities.

**Submission Methods** **_Mail_**

National Government Services, Inc. Medical Policy Unit Attention: LCD
Reconsideration Request P.O. Box 7108 Indianapolis, IN 46207-7108

**_E-Mail_**

[NGS.lcd.reconsideration@anthem.com](mailto:NGS.lcd.reconsideration@anthem.com)

**_Fax_** (317) 595-4334

**National Government Services Response** Within **60 days** of the day the
request is received, National Government Services will determine whether the
request is valid or invalid and will notify the requestor of the
determination.

**Valid Request Possible Actions**

If the request is valid, NGS will either open the LCD and follow the LCD
process as outlined in CMS Publication 100-08, Medicare Program Integrity
Manual, Chapter 13, Section 13.2, or include the LCD on the MAC's waiting
list.

**Invalid Request Action**

If the request is invalid, NGS will explain the reason(s) it was invalid.  
  
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