Corporate

LCD Reconsideration Process

Note:  This process is for the reconsideration of a local coverage determination (LCD), not individual claims.

The Local Coverage Determination (LCD) Reconsideration process is a method by which interested parties can request a revision to an active LCD.  CGS follows the Centers for Medicare & Medicaid Services (CMS) Program Integrity Manual (Internet-only Manual 100-08), Chapter 13 process for LCD Reconsiderations. The reconsideration process is available for final, effective LCDs only. The entire LCD or any part of it is subject to reconsideration.  The process for LCD Reconsideration is outlined below.

Request Submission Criteria (Required)

CGS will consider all LCD reconsideration requests from:

  • Beneficiaries residing or receiving care in our contractor's jurisdiction; and
  • Providers doing business in our contractor's jurisdiction.
  • Any interested party doing business in our contractor's jurisdiction

Reconsideration requests are only accepted for LCDs published in final form.  Requests will not be accepted for other documents including:

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

CGS has the discretion to consolidate valid requests if similar requests are received. Any request for LCD reconsideration that, in the judgment of the contractor, does not meet these criteria is invalid.

CGS may revise or retire their LCDs at any time on their own initiatives.

If modification of the final LCD would conflict with an NCD, the request will not be valid. For information about the NCD reconsideration process, reference http://www.cms.gov/DeterminationProcess/01_overview.asp#regsExternal Website. Information about requesting an NCD or an NCD revision is found under "How to Request an NCD" in the Coverage Process section.

Should the requestor continue with a formal LCD Reconsideration request, a valid request must include the following:

  1. The specific language that the requestor proposes added to or deleted from an LCD; and,
  2. Justification for the proposed change supported by new evidence in the medical literature which will materially affect the LCDs content or basis.  Electronic copies of published (i.e., not embargoed), English language, full-text articles are required.

The level of evidence required for LCD reconsideration is the same as that required for new/revised LCD development (see Program Integrity Manual, Chapter 13).

How To Submit Request:

LCD reconsideration requests may be sent via one of three methods: email, hard copy by mail, or fax. Below lists pertinent information for each of the three methods:

  1. Email : CMD.INQUIRY@cgsadmin.com
    • Electronic requests should be sent with "LCD Reconsideration Request – [Name of LCD]" in the subject line.
    • If the attachment size for clinical citations exceeds 15 MB, the requestor must send the articles and supporting documents via multiple, smaller emails.
    • Please contact CMD.INQUIRY@cgsadmin.com for alternative methods for submitting large electronic files or if you have difficulty submitting an LCD Reconsideration request.
  2. Fax: 615.664.5971
    • Please address your fax cover sheet to J15 LCD Reconsideration - Attn: Chief Medical Director
    • Note: This fax line for the LCD reconsideration process described above.   
  3. Mail:

    CGS Administrators
    Attn: Chief Medical Director
    J15 A/B MAC LCD Reconsideration
    Two Vantage Way
    Nashville, Tennessee 37228

    Please note that this information is for J15 MAC LCD reconsiderations only.

Next Steps

CGS will review materials received within 60 calendar days upon receipt and determine whether the request is valid or invalid.  If the request is invalid CGS will respond, in writing, to the requestor explaining why the request was invalid. 

A valid request response does not convey that a determination has been made whether or not the item or service will be covered or non-covered under 1862 (a)(1)(A) of the Act. The response to the requestor that the request is valid is simply an acknowledgement to the requestor of the receipt of a complete, valid request.

If the request is valid, the J15 will follow the process for LCD reconsiderations detailed in the Centers for Medicare & Medicaid Services (CMS) Program Integrity Manual (Internet-only manual 100-08), Chapter 13.  Once the submitted material is reviewed, you will be contacted should the CMDs have additional questions. If there are no additional questions from the CMDs, you should monitor the J15 MAC web sites and listservs for the posting of a proposed LCD, date and time for a public meeting and timeline for completion of your reconsideration request.  This information can be found under the Local Coverage Determinations link on the J15 Part A, B, and HHH web site- Medical Policies.

CGS will post updates to the LCD Summary Sheet on the Medicare Coverage Database web siteExternal Website.  Final LCDs will be finalized or retired within a rolling calendar year of publication date on the Medicare Coverage Database (365 days).

Related Information

Updated 12.26.18


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