The LCD reconsideration process is a mechanism for interested parties to request a revision to an LCD. The process is available only for final effective LCDs. The entire LCD or any provision of the LCD may be reconsidered.
Review our LCD Reconsideration Request Process flowchart
LCDs are developed to convey under what circumstances an item/service is considered to be reasonable and necessary. We will consider reasonable and necessary services for payment in the absence of an LCD, billing and coding article, NCD, or CMS manual instruction limiting coverage.
All LCDs must be based on evidence. Please read our Evidence-based Health Policy: Literature Review Methodology for Local Coverage Determinations article for guidance on the strength of medical literature/evidence that may be submitted for consideration.
1. LCD reconsideration requests will be considered from:
Beneficiaries residing or receiving care in Novitas Solutions’ Jurisdictions H or L (JH, JL);
Health care professionals doing business in Novitas Solutions’ jurisdictions;
Any interested party doing business in Novitas Solutions’ jurisdictions.
2. Valid LCD reconsideration request requirements:
LCD reconsideration requests must be submitted in writing and must identify the language that the requestor wants added to or deleted from an LCD.
Requests must include a justification for the proposed change supported by new evidence not already listed in the LCD’s Sources of Information/Bibliography, which may materially affect the LCDs content or basis. Electronic copies of literature are preferred. Medical literature must be published, include the full text (not abstracts), and be in English.
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 Novitas Solutions;
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. Please refer to our
New LCD Request Process for this type of request.
3. How to submit a request:
Novitas LCDs apply to all states within our JH and JL contracts; therefore, only one request needs to be submitted to encompass both jurisdictions. LCD reconsideration requests may be sent via one of the three methods below:
By E-mail
If the attachment size for clinical citations exceeds 10 MB, the requestor must send the valid articles and supporting documents via multiple, smaller e-mails. Please contact
medicalaffairs@guidewellsource.com for alternative methods for submitting large electronic files or if you have difficulty submitting an LCD reconsideration request.
By Fax:
Requests should be faxed to: 717-526-6389. Please notate on your fax cover sheet “Attention: Medical Affairs – LCD Reconsideration Request – [LCD number and title]”.
By U.S. Postal Service:
Office of the Contractor Medical Director
Novitas Solutions
Medical Affairs Department
2020 Technology Parkway, Suite 100
Mechanicsburg, PA 17050
4. After a reconsideration request is received:
Within 60 calendar days of the date the request is received, Novitas Solutions will determine if the request is valid or invalid:
Any request for a LCD reconsideration that, in the judgment of Novitas Solutions, does not meet the criteria described above, is invalid. If the request is invalid, Novitas Solutions will respond, in writing, to the requestor explaining why the request was invalid.
A valid request 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 is an acknowledgement only of the receipt and acceptance of a valid request.
The request then goes on our waitlist to undergo our internal prioritization process which includes review of literature submitted. This process can take up to 12 months or more to complete. Topics are prioritized based on claims data, including how often a service is billed and the frequency a service is being denied. Access to care as well as associated quality health outcomes are also considered.
Our website will be used to notify requestors and potentially interested parties of LCD revisions. If a requested LCD revision needs to be taken to our Contractor Advisory Committee (CAC) for evidentiary review we will publish notice of the
CAC meeting to our website. If it is determined that a CAC meeting is not required, the revision will be posted for open comment and presented at an Open Meeting. When a proposed LCD is posted for open comment period, we will publish notice of the
proposed LCD and
Open meeting.
Source:
CMS IOM Publication 100-08, PIM, Chapter 13, Section 13.3.2
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