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| Local Coverage Determination (LCD) Reconsideration Process |
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Revised 5-4-06
The LCD Reconsideration Process is a mechanism by which interested parties can request a revision to an LCD. This process is available only for final LCDs and is effective October 1, 2002. The whole LCD or any part of the LCD may be reconsidered, i.e., Benefit Category provisions, Utilization Guidelines, Covered ICD-9-CM codes, etc.
The contractor will consider requests for policy (LCD) revision from the following sources:
- Beneficiaries residing or receiving care in the contractor's jurisdiction;
- Providers doing business in the contractor's jurisdiction;
- Other interested parties doing business in the contractor's jurisdiction (this is at carrier discretion).
Medicare may not accept reconsideration requests on the following documents:
- National Coverage Decisions (NCDs);
- Coverage provisions in interpretive manuals;
- Draft LCDs;
- Template LCDs, unless or until they are adopted by the contractor;
- Retired local medical review policies (LMRPs)/LCDs;
- Individual claim determinations;
- Bulletins, articles, training materials; and
- Any instance in which no LCD exists, i.e., requests for development of an LCD.
If modification of the LCD would conflict with an NCD, the request would not be valid. The Medicare contractor will then refer the requestor to the NCD reconsideration process at www.cms.hhs.gov/Rulings/downloads/CMSR0101.pdf.
Requests must be submitted in writing, and must identify the language that the requestor wants added to or deleted from an LCD. As a suggestion, use an electronic or paper copy of the LCD, put a line through the language/codes you want changed or removed and supply the exact language/codes you want added.
Requests must include a justification supported by new evidence (please review the current LCD to determine which references have already been considered), which may materially affect the LCDs content or basis. Copies of new published evidence must be included. It is not sufficient to list sources.
Requests can be submitted in writing via the following avenues.
Online:
www.umd.nycpic.com/webapps/umdforms/localrecwww.nsf/w_rec_main?OpenForm
Mail:
Janet M. Skrzypek
Upstate Medicare Division
P.O. Box 5237
Binghamton, NY 13902-5237
Fax:
607-766-6452
Within 30 days of receipt, the carrier will notify the requestor whether the request is valid, i.e., meets all criteria listed above.
If the request is deemed valid, the carrier, within 90 days, will determine whether the requested change to the policy will be accepted. The requestor will be notified of the decision, whether the request is accepted or not.
If accepted, the policy will be revised through the carrier's usual process. |
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