LCD Reconsideration Process

Home MAC Provider Policies/Coverage LCD Reconsideration Process

Purpose

The LCD Reconsideration Process is a mechanism by which interested parties can request a revision to a finalized Local Coverage Determination (LCD). WPS has a formal process for LCD reconsideration.

Non-Valid LCD Reconsideration Requests

The reconsideration process does not pertain to complaints filed under Section 1869(f) of the Social Security Act concerning a national or local coverage determination. A carrier or intermediary must forward Section 1869(f) complaints to the Social Security Administration's Office of Hearings and Appeals for resolution.

The reconsideration process does not pertain to other documents including:

  • National Coverage Determinations (NCD)
  • Coverage provisions in interpretive manuals (NCP)
  • Draft LCDs
  • Template LCDs, unless or until they are adopted by the contractor
  • Retired LCDs
  • Individual claim determinations
  • Bulletins, articles, training materials
  • Any instance in which no LCD exists, i.e., requests for development of an LCD

Reconsideration requests must not place an LCD in conflict with a National Coverage Determination (NCD). Such requestors will be referred to the NCD reconsideration process (www.cms.hhs.gov/DeterminationProcess/ link to CMS Website).

Valid LCD Reconsideration Requests

The LCD reconsideration process is available only for final LCDs. The whole LCD or any part/section of the LCD may be reconsidered, such as the Benefit Category Provisions, Utilization Guidelines, and Covered ICD-9 Codes.

The LCD reconsideration process requires the same level of evidence required in development of a new LCD. LCDs must be based on the strongest evidence available. The extent and quality of supporting evidence is key to defending challenges to LCDs. The initial action in gathering evidence to support LCDs must always be a search of published scientific literature for any available evidence pertaining to the item/service in question. LCDs and reconsideration requests should be based on:

  • Published authoritative evidence derived from definitive randomized clinical trials or other definitive studies, and
  • General acceptance by the medical community (standard of practice), as supported by sound medical evidence based on:
  • Scientific data or research studies published in peer-reviewed medical journals;
  • Consensus of expert medical opinion (i.e., recognized authorities in the field); or
  • Medical opinion derived from consultations with medical associations or other health care experts.

The reconsideration process for WPS-Medicare LCDs is open:

  • To beneficiaries residing or receiving care in our jurisdiction (Iowa, Kansas, Missouri and Nebraska) and
  • Providers doing business in our jurisdiction; or
  • We may consider requests from other parties doing business in our jurisdiction.

In addition, WPS will continue to revise or retire our LCDs at any time on our initiative.

A request for LCD reconsideration that, in the judgment of WPS, does not meet the above criteria is invalid. WPS may consolidate similar, valid requests.

Process

  1. Requests must be submitted in writing, identifying the language that the requestor wants added to or deleted from an LCD. Requests must include a justification supported by new evidence, which may materially affect the LCD's content or basis. Copies of published evidence must be included.
  2. The level of evidence presented with the request must meet the level of evidence required for development of a new LCD. See above.
  3. The requestor may submit a valid LCD reconsideration request to WPS by postal mail, e-mail, or fax to the MAC J5 Medical Director:

    Kenneth L. Bussan, M.D.
    Wisconsin Physicians Service
    1707 W. Broadway
    Madison, WI 53713
    Kenneth.Bussan@wpsic.com
    Fax: (608)-301-2625


  4. Within 30 days of the day the request is received, WPS will determine whether the request is valid or invalid. If the request is invalid, we will respond, in writing, explaining why the request was invalid. If the request is valid, we will follow the requirements in 5, 6, and 7 as applicable
  5. Within 90 days of the day the request was received, we will make a final LCD reconsideration decision on the valid request and notify the requestor of the decision with its rationale. Decision options include retiring the local coverage determination, no revision, revision to a more restrictive local coverage determination, or revision to a less restrictive local coverage determination.
  6. If the decision is either to retire the LCD or to make no revision to the LCD, we will, within 90 days of the day the request was received, inform the requestor of the decision with its rationale.
  7. If the decision is to revise the LCD, we will follow the normal process for LCD development.

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Page Last Updated: Wednesday, 31-Dec-2008 10:48:32 CST