Article - Local Coverage Determination (LCD) Reconsideration Process - Medical Policy Article (A52842)

CMS National Coverage PolicyN/AArticle TextThe 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 ProcessThe 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 forfinal, effective LCDs. The whole LCD or any provision of the LCD may be reconsidered.Reconsideration Requests May Be Submitted ByNational 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]jurisdictionAny interested party doing business in[our]jurisdiction.Acceptable RequestsThe LCD Reconsideration Process is available only for final, effective LCDs. The whole LCD or any provision of the LCD may be reconsidered.Unacceptable RequestsRequests are not accepted for other documents including:National Coverage Determinations (NCDs)Coverage provisions in interpretive manualsProposed LCDs;Template LCDs, unless or until they are adoptedand in effectby the contractor;Retired LCDs;Individual claim determinations;Bulletins, articles, training materials; andAny instance in which no LCD exists,i.e, requests for development of an LCD.Submission Documentation RequirementsRequests must be submitted in writing and include the following items: name and address of beneficiary or provider; orif 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 businesse-mail address (preferred);telephone number (optional)the name of the final, effective LCD, andcopies of published evidence, andlanguage 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 MethodsMailNational Government Services, Inc. Medical Policy Unit Attention: LCD Reconsideration Request P.O. Box 7108 Indianapolis, IN 46207-7108E-MailNGS.lcd.reconsideration@anthem.comFax(317) 595-4334National Government Services ResponseWithin60 daysof 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 ActionsIf 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 MACs waiting list.Invalid Request ActionIf the request is invalid, NGS will explain the reason(s) it was invalid.