The LCD and NCD Reconsideration Processes
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The LCD and NCD Reconsideration Processes
You currently have jurisdiction selected, however this page only applies to these jurisdiction(s): .
The Social Security Act defines what items and services Medicare is allowed to cover. However, CMS and Medicare Administrative Contractors (MACs) determine how to apply the Social Security Act requirements to the processing of claims. For some items and services, Medicare defines coverage guidelines by issuing Local Coverage Determinations (LCDs) or National Coverage Determinations (NCDs). Local MACs (like WPS GHA) issue LCDs that apply only to items or services provided within the MAC’s local jurisdiction. CMS issues NCDs that apply nationwide.
Anyone directly impacted by an LCD or NCD may ask the entity that created the coverage determination (i.e., the MAC or CMS) to reconsider the provisions of the LCD or NCD.
Local Coverage Determination (LCD) Reconsideration Process
As of December 31, 2019, we removed all CPT/HCPCS and ICD-10 codes from the LCDs and placed them in related Billing and Coding Articles. If you are just requesting a change to codes for a condition already covered in an LCD, please send your request to policycomments@wpsic.com. The process below is for requesting changes to LCDs only.
Purpose of the LCD Reconsideration Process
The LCD reconsideration process is a method by which interested parties can request a revision to a Final LCD currently in effect. The following parties may request an LCD reconsideration:
- Beneficiaries residing or receiving care in a contractor's jurisdiction
- Providers doing business in a contractor's jurisdiction
- Any interested party doing business in a contractor's jurisdiction
You can find information about the LCD reconsideration process in the CMS Internet-only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Local Coverage Determinations , Section 13.3.
Note: This process is for the reconsideration of an LCD, not individual claims. If you would like to appeal a claim determination, see our article, “How to Appeal a Claim Determination.”
Components of an LCD Reconsideration Request
Interested parties can ask us to reconsider an entire LCD or just a part of it. A valid LCD reconsideration request must include:
- The specific language that the requestor proposes added to or deleted from an LCD. For example, “We request coverage of X condition due to new evidence for the surgical management described in this LCD.”
- A description of the statutorily defined benefit category under which the requestor believes the item or service falls. The request must include a rationale justifying the assignment within that benefit category. The CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, defines the benefit categories.
- Justification for the proposed change supported by new evidence in the medical literature that may materially affect the LCD’s content or basis. The level of evidence required for LCD reconsideration is the same as that required for a new LCD development.
- We prefer to receive electronic copies of supporting medical literature as email attachments. Medical literature must be currently published, include the full text (not abstracts), and in be published in English. Due to security restrictions, we are not able to open links in emails.
- Information that addresses the relevance, usefulness, clinical health outcomes, or the medical benefits of the item or service.
- Information that fully explains the design, purpose, and/or method, as appropriate, of using the item or service for which you are making the request.
How to Submit a an LCD Reconsideration Request
LCD reconsideration requests may be sent to WPS GHA via one of three methods: email (preferred), mail, or fax. Below lists pertinent information for each of the three methods:
- Email
- Send electronic requests to policycomments@wpsic.com with "LCD Reconsideration Request – [Name of LCD]" in the subject line.
- Please consider limiting the amount of medical literature you send by providing a meta-analysis, or by selecting five (5) published medical literature/documents that are germane to your issue of coverage that best support your reconsideration request.
- Attachments may not exceed 15 MB. If the attachment size for clinical citations exceeds 15 MB, you must send the articles and supporting documents via multiple, smaller emails. Please contact policycomments@wpsic.com for alternative methods for submitting large electronic files or if you have difficulty submitting an LCD reconsideration request.
- Fax
- Fax requests and supporting documentation to (608) 977-9896. Please address your fax cover sheet to LCD “Reconsideration request – Attn: Policy Department.”
- Mail
- Mail requests and supporting documentation to the following address:
WPS GHA
Attn: Medical Policy Department
1717 W. Broadway
P.O. Box 1787
Madison, WI 53701
- Mail requests and supporting documentation to the following address:
What to Expect after Submitting an LCD Reconsideration Request
The WPS GHA Policy department will review materials to determine whether the request is valid or invalid. We will respond to the requestor in writing within 60 days regarding the validity of the redetermination request, or we will contact you if the Contractor Medical Directors (CMDs) have additional questions. If the request is valid, we will follow the LCD reconsideration process outlined in the CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Local Coverage Determinations . Alternatively, we may place the LCD reconsideration on our waiting list. If the request is invalid, WPS GHA will respond, in writing, to the requestor explaining why the request was invalid.
Note: Notification that a request is valid or invalid does not mean we made a coverage decision about the item or service. The response to the requestor that the request is valid is simply an acknowledgement that we received a complete, valid request.
Please monitor the WPS GHA website and eNews for the posting of a proposed reconsideration of an LCD, and the date and time for a public meeting. The coverage in the current LCD will remain in effect during the reconsideration process.
National Coverage Determination (NCD) Reconsideration Process
Any individual or entity may request that CMS reconsider any provision of an NCD by filing an acceptable request for an NCD reconsideration with CMS. CMS will consider a request to revise an existing NCD at any time, but only if the requestor presents documentation that meets certain criteria. You can access this CMS notification in the Federal Register (78 FR 48164-69) .
For more information about the NCD reconsideration process, including where to send a request, see the CMS website.
global-tags: Featured Guides and Resources,Local Coverage,J8A,J5A,Policies,J8B,J5B,National Coverage
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LCD Reconsideration Request: Policycomments@wpsic.com
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