LCD Reconsideration Process

The Local Coverage Determination (LCD) Reconsideration process is a method by which interested parties can request a revision to an active LCD. Palmetto GBA 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.

Informal Teleconference (Optional)
Prior to submitting a formal LCD Reconsideration, Palmetto GBA encourages requestors to schedule an informal conference call to review the requirements for a valid LCD Reconsideration request. Request for a conference call may be submitted via email to A.Policy@palmettogba.com, B.Policy@palmettogba.com or MolDX.Policy@palmettogba.com. In the request for an informal discussion, requestors should include the following information:

1. Include in the subject line of the email: "Request for LCD Reconsideration Call – [Title of LCD]"
2. Several options for dates and times for a 30 minute - 1 hour conference call
3. Teleconference number with enough lines to accommodate 15 participants
4. Agenda for the call, including requestor participants and titles
5. Summary information (1-2 paragraphs, maximum) for the reconsideration request

Request Submission Criteria (Required)
Palmetto GBA will consider all LCD reconsideration requests from:

• Beneficiaries residing or receiving care in our contractor's jurisdiction
• 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 Determinations (NCDs)
• Coverage provisions in interpretive manuals
• Proposed LCDs
• Template LCDs, unless or until they are adopted by the contractor and become effective
• Retired LCDs
• Individual claim determinations
• Bulletins, articles, training materials
• Any instance in which no LCD exists, i.e., requests for development of an LCD

Palmetto GBA 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.

Palmetto GBA 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 the CMS website. Information about requesting an NCD or an NCD revision is found under "How to Request an NCD" in the Coverage Process section.

Following the informal discussion, should the requestor wish to continue with a formal LCD Reconsideration request, a valid request must include:

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 (preferred), hard copy by mail, or fax. Below lists pertinent information for each of the three methods:

1. Email (Preferred Method): A.Policy@palmettogba.com, B.Policy@palmettogba.com or MolDX.Policy@palmettogba.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 one of the mailboxes above for alternative methods for submitting large electronic files or if you have difficulty submitting an LCD Reconsideration request
2. Fax:
   • JM Part A/HHH (803) 462-2652 or JM Part B (803) 382-2424
   • JJ Part A (803) 870-0133 or JJ Part B (803) 870-0137
   • Please address your fax cover sheet to Palmetto GBA LCD Reconsideration -- Attn: Medical Affairs
   • Note: This fax line for the LCD reconsideration process described above. This is not the fax line for appealing individual claims (Redeterminations)
3. Mail:
   • Jurisdiction M
     Palmetto GBA
     Attn: Medical Affairs
     PO Box 100238
     Columbia, SC 29202-3238
     
   • Jurisdiction J
     Palmetto GBA
     Attn: Medical Affairs
     PO Box 100305
     Columbia, SC 29202-3305

Please note that this information is for Palmetto GBA LCD reconsiderations only. Information for submitting an LCD reconsideration request for other Jurisdictions may be found on their websites.

Next Steps
Palmetto GBA will review materials received within 60 calendar days upon receipt and determine whether the request is valid or invalid. If the request is invalid Palmetto GBA 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, Palmetto GBA 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 Palmetto GBA have additional questions. If there are no additional questions from Palmetto GBA, you should monitor the Palmetto GBA websites and listservs for the posting of a proposed LCD, date and time for an open meeting and timeline for completion of your reconsideration request. This information can be found under the Medical Policies section of the Palmetto GBA website.

Related Information: Medicare Program Integrity Manual, Chapter 13 – Local Coverage Determinations (PDF, 217 KB)