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All are required fields unless otherwise noted

Which type of policy change are you requesting?


(Depending on choice above, a new page will open with the specific fields for that particular request)

If answer "New LCD Request" Fields

Please indicate your status: (Radio Buttons)

Medicare Beneficiary
Health Care Professional (specify degree)
Manufacturer
Supplier
Clinical Organization (Specify Name)
Industry Trade Organization/Coalition (Specify Name)
Individual Physician/Non-Physician Practitioner
Consultant (Specify Client)
Other (Specify)

Prior to submitting a formal LCD request, the DME MACs encourage requestors to schedule an informal conference call to review the requirements for a valid LCD request. Would you like to schedule a call to discuss the new LCD request?

Yes

Requestor Information
First name:
Last name:
Email:
Phone: - -
Title of Proposed New LCD
Please indicate three (3) potential dates and times for an informal call.
  1. at
  2. at
  3. at
Please provide teleconference number with enough lines to accommodate 15 participants
Teleconference number: - -
Teleconference ID:
Passcode:
 
Agenda - REQUIRED:
Attachment 1:
Attachment 2:
Attachment 3:
Attachment 4:
No
The following fields must be completed in order for a new LCD request to be considered valid.
Clearly identify the statutorily-defined Medicare benefit category to which you believe the item or service falls under: (Radio Buttons)

CMS Benefit Policy Manual Chapter 15

  • 1861(s)(2)(J) – Immunosuppressive drugs
  • 1861(s)(2)(Q) – Oral anticancer drug
  • 1861(s)(2)(T) – Oral anti-emetic drugs
  • 1861(s)(2)(Z) – Intravenous immunoglobulin (IVIG) for primary immune deficiency
  • 1861(s)(5) – Surgical dressings
  • 1861(s)(6) – Durable medical equipment
  • 1861(s)(8) – Prosthetic devices (other than dental) and colostomy bags and colostomy supplies; eyeglasses and contacts following cataract surgery
  • 1861(s)(9) – Leg, arm, back and neck braces (i.e., orthotics) and artificial legs, arms and eyes (i.e., prosthetic limbs)
  • 1861(s)(12) – Therapeutic shoes for persons with diabetes
  • 1861(zz) – Intravenous Immune Globulin
Provide a rationale for the benefit category selected above:

Supporting documentation:

What specific coverage or non-coverage language do you want in the new LCD?

Supporting documentation:

Evidence justifying the new LCD must be supported by peer-reviewed clinical literature. Full-text copies (not abstracts or meeting poster presentations) of published evidence from peer-reviewed literature must accompany the request. Failure to include full-text clinical literature invalidates the request. Please attach individual articles below (XXMB limit per file):

LCD evidence information in CMS Program Integrity Manual, Chapter 13, Section 13.7.1

Attachment 1 - REQUIRED:
Attachment 2:
Attachment 3:
Attachment 4:
Title of Proposed New LCD
Please provide information that addresses the relevance, usefulness, clinical health outcomes, or the medical benefits of the item or service that the new LCD will address:

Supporting documentation:

Please provide information that fully explains the design, purpose, and/or method, as appropriate, of using the item or service for which the new LCD is expected to address:

Supporting documentation:

(Optional) Please provide the ICD-10 codes that would apply to this request:

Supporting documentation:

If answer "Existing LCD Reconsideration"

Please indicate your status: (Radio Buttons)

  • Medicare Beneficiary
  • Health Care Professional (specify degree)
  • Manufacturer
  • Supplier
  • Clinical Organization (Specify Name)
  • Industry Trade Organization/Coalition (Specify Name)
  • Individual Physician/Non-Physician Practitioner
  • Consultant (Specify Client)
  • Other (Specify)

Select existing LCD for reconsideration: (Drop down menu with list of current LCDs)

Prior to submitting a formal LCD request, the DME MACs encourage requestors to schedule an informal conference call to review the requirements for a valid LCD request. Would you like to schedule a call to discuss the new LCD request? (Radio Buttons)

  • Yes (Goes to "Yes" questions to schedule a call)
  • No (Goes directly to new LCD request)

(Depending on choice above, a new page will open with the specific fields for that particular request)

If answer "Yes" to Informal Meeting
Requestor Information Fields

  • First and Last Name
  • Title
  • Email Address
  • Phone Number
  • Please indicate three (3) potential dates and times for an informal call.
    • Calendar with 1 hour slots on Tues, Thur and Fri from 9-11 AM CDT – Must pick 3 options - on different days – Allow DMDs to block off certain days when calls not available
  • Please provide teleconference number with enough lines to accommodate 15 participants
    • Field for Teleconference number and passcode supplied by requestor
  • Description of technology, product or service for which the LCD reconsideration is requested (Narrative field with 1000 character maximum)
  • At a minimum, an agenda is required before scheduling a call. If you have presentation materials, please upload those documents below (XXMB limit per file):
    • 1 upload field is mandatory (for the agenda)
    • 4 additional upload fields with option to add more if needed.

If answer "No" to Informal Meeting
Requestor Information Fields

  • First and Last Name
  • Title
  • Email Address
  • Phone Number

The following fields must be completed in order for an LCD reconsideration request to be considered valid.

What specific coverage or non-coverage language do you want added or deleted from the LCD?

  • Narrative field with 1000 character maximum and
  • 1 upload field

Evidence justifying the LCD change must be supported by peer-reviewed clinical literature. Full-text copies (not abstracts or meeting poster presentations) of published evidence from peer-reviewed literature must accompany the request. Failure to include full-text clinical literature invalidates the request. Please attach individual articles below (XXMB limit per file):

  • 1 upload field is mandatory
  • 4 additional upload fields with option to add more if needed.

(Consider displaying hyperlink to LCD evidence information in CMS Program Integrity Manual, Chapter 13, Section 13.7.1)

(Optional) Please provide the ICD-10 codes that would apply to this request:

  • Narrative field with 1000 character maximum and
  • 1 upload field

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