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Article for Local Coverage Determination (LCD) Reconsideration Process - Medical Policy Article (A52842)


Contractor Information

Contractor Name Contract Type Contract Number Jurisdiction State(s)
National Government Services, Inc. HHH MAC 06004 - HHH MAC J - 06 Alaska American Samoa Arizona California - Entire State Guam Hawaii Idaho Michigan Minnesota New Jersey Nevada New York - Entire State Oregon Puerto Rico Virgin Islands Washington Wisconsin Northern Mariana Islands
National Government Services, Inc. MAC - Part A 06101 - MAC A J - 06 Illinois
National Government Services, Inc. MAC - Part B 06102 - MAC B J - 06 Illinois
National Government Services, Inc. MAC - Part A 06201 - MAC A J - 06 Minnesota
National Government Services, Inc. MAC - Part B 06202 - MAC B J - 06 Minnesota
National Government Services, Inc. MAC - Part A 06301 - MAC A J - 06 Wisconsin
National Government Services, Inc. MAC - Part B 06302 - MAC B J - 06 Wisconsin
National Government Services, Inc. A and B and HHH MAC 13101 - MAC A J - K Connecticut
National Government Services, Inc. A and B and HHH MAC 13102 - MAC B J - K Connecticut
National Government Services, Inc. A and B and HHH MAC 13201 - MAC A J - K New York - Entire State
National Government Services, Inc. A and B and HHH MAC 13202 - MAC B J - K New York - Downstate
National Government Services, Inc. A and B and HHH MAC 13282 - MAC B J - K New York - Upstate
National Government Services, Inc. A and B and HHH MAC 13292 - MAC B J - K New York - Queens
National Government Services, Inc. A and B and HHH MAC 14014 - HHH MAC J - K Connecticut Massachusetts Maine New Hampshire Rhode Island Vermont
National Government Services, Inc. A and B and HHH MAC 14111 - MAC A J - K Maine
National Government Services, Inc. A and B and HHH MAC 14112 - MAC B J - K Maine
National Government Services, Inc. A and B and HHH MAC 14211 - MAC A J - K Massachusetts
National Government Services, Inc. A and B and HHH MAC 14212 - MAC B J - K Massachusetts
National Government Services, Inc. A and B and HHH MAC 14311 - MAC A J - K New Hampshire
National Government Services, Inc. A and B and HHH MAC 14312 - MAC B J - K New Hampshire
National Government Services, Inc. A and B and HHH MAC 14411 - MAC A J - K Rhode Island
National Government Services, Inc. A and B and HHH MAC 14412 - MAC B J - K Rhode Island
National Government Services, Inc. A and B and HHH MAC 14511 - MAC A J - K Vermont
National Government Services, Inc. A and B and HHH MAC 14512 - MAC B J - K Vermont

Article Information

General Information

Article ID

A52842

Original ICD-9 Article ID

A47355

Article Title

Local Coverage Determination (LCD) Reconsideration Process - Medical Policy Article

Original Article Effective Date

10/01/2015

Revision Effective Date

01/01/2019

Revision Ending Date

N/A

Retirement Date

N/A

AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT only copyright 2002-2016 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association.

UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association (“AHA”), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA.” Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company.

Article Guidance

Article Text:

The requirements in this article are based on instructions found in CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.3.1, 13.3.2 and 13.3.3. 

Reconsideration Request Process

The LCD reconsideration process is a mechanism by which a beneficiary or stakeholder (including a medical professional society or physician) in NGS jurisdiction can request a revision to an LCD. The LCD reconsideration process differs from an initial request for an LCD in that it is available only for final, effective LCDs. The whole LCD or any provision of the LCD may be reconsidered.

Reconsideration Requests May Be Submitted By National Government Services will consider all LCD reconsideration requests from:

    • Beneficiaries residing or receiving care in [our] jurisdiction (Alaska, American Samoa, Arizona, California, Connecticut, Guam, Hawaii, Illinois, Idaho, Maine, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, New York, Northern Mariana Islands, Oregon, Puerto Rico, Rhode Island, Vermont, U. S. Virgin Islands, Virginia, Washington, West Virginia and Wisconsin);
    • Providers doing business in [our] jurisdiction
    • Any interested party doing business in [our] jurisdiction.

Acceptable Requests The LCD Reconsideration Process is available only for final, effective LCDs. The whole LCD or any provision of the LCD may be reconsidered.

Unacceptable Requests

Requests are not accepted for other documents including:

    • National Coverage Determinations (NCDs)
    • Coverage provisions in interpretive manuals
    • Proposed LCDs;
    • Template LCDs, unless or until they are adopted and in effect 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.

Submission Documentation Requirements

Requests must be submitted in writing and include the following items:

· name and address of beneficiary or provider; or

    • if the requestor is neither a beneficiary, nor a provider, the name and address of the organization he/she represents and the nature of that organization's business
    • e-mail address (preferred);
    • telephone number (optional)
    • the name of the final, effective LCD, and
    • copies of published evidence, and
    • language wanted to be added to or deleted from the LCD.

Submission Methods Mail

National Government Services, Inc. Medical Policy Unit Attention: LCD Reconsideration Request P.O. Box 7108 Indianapolis, IN 46207-7108

E-Mail

NGS.lcd.reconsideration@anthem.com

Fax (317) 595-4334

National Government Services Response Within 60 days of the day the request is received, National Government Services will determine whether the request is valid or invalid and will notify the requestor of the determination.

Valid Request Possible Actions

If the request is valid, NGS will either open the LCD and follow the LCD process as outlined in CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.2, or include the LCD on the MAC’s waiting list.

Invalid Request Action

If the request is invalid, NGS will explain the reason(s) it was invalid.


Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

CPT/HCPCS Code Description
XX000 Not Applicable

ICD-10 Codes that are Covered

ICD-10 Codes that are Not Covered

N/A


Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2019
R5
Based on CR10901, the Reconsideration Process has been revised.
01/15/2018 R4 Removed contact name for submission of LCD reconsideration requests.
01/15/2018 R3 Updated the fax number for LCD reconsideration requests.
01/15/2016 R2 Updated the fax number for LCD reconsideration requests.
10/01/2015 R1 Removed CPC credentials.

Added a clarification that scientific data or research studies published in peer-reviewed medical journals must be indexed on PubMed (from the US National Library of Medicine, National Institute of Health).

Removed the telephone number for the Provider Outreach and Education Department. Reformatted items under the ?"Information to be Submitted"? section to be consistent with the Medicare Program Integrity Manual.

Associated Documents

Related Local Coverage Document(s)

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Related National Coverage Document(s)

N/A

Statutory Requirements URL(s)

N/A

Rules and Regulations URL(s)

N/A

CMS Manual Explanations URL(s)

N/A

Other URL(s)

N/A

Public Version(s)
Updated on 12/18/2018 with effective dates 01/01/2019 - N/A
Updated on 06/19/2018 with effective dates 01/15/2018 - N/A
Updated on 01/04/2018 with effective dates 01/15/2018 - N/A
Updated on 01/28/2016 with effective dates 01/15/2016 - N/A
Some older versions have been archived. Please visit MCD Archive Site to retrieve them.


Keywords

N/A

Article for Local Coverage Determination (LCD) Reconsideration Process - Medical Policy Article (A52842)
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