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MMA 2003

Appeals of Local Coverage Determinations

What is a "Local Coverage Determination" (LCD)?

Medicare Carriers and Fiscal Intermediaries (FIs) are private companies that Medicare contracts with to pay bills. Carriers and FIs make coverage decisions in their area about what items or services are reasonable and necessary.

Who can appeal an LCD?

You can appeal an LCD if:

  1. you are entitled to benefits under Medicare Part A, are enrolled under Medicare Part B, or both, and
  2. you must need or have already received the item(s) or service(s) determined not covered by the LCD

The estate of a person with Medicare, who meets the criteria above, can appeal an LCD review if:

  1. the person with Medicare died after they requested an LCD review of an item or service they received; or
  2. the estate received a denial notice. The LCD review must be requested within 120 days of receiving the denial notice.

When can I file an LCD Appeal?

If you are entitled to Medicare and have not received the item or service, you must file your request:

  • within 6 months of the date of the treating physician's written statement that you need to get that item or service.

If you are entitled to Medicare and have already received the item or service, you must file your request:

  • within 120 days of the date of the initial denial notice from the Carrier or FI that used the LCD. The Medicare Summary Notice (MSN) you get explains what was charged and what was paid. It also may include a denial notice that explains that an LCD does not cover a certain item or service. This is because that item or service is considered not reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the function of a malformed part of the body.

Where do you file an LCD appeal request?

LCD appeal requests must be sent to:

         Departmental Appeals Board
         Civil Remedies Division, Mail Stop 6132
         Cohen Building, Room G-644
         330 Independence Avenue, S.W.0
         Washington, DC 20201

What information must I include in my LCD appeal request?

When you file an LCD appeal request, include:

  1. the name of the person entitled to Medicare,
  2. his/her address,
  3. telephone number, and
  4. health insurance claim number if applicable.

If the person with Medicare has designated an authorized representative, include:

  1. their full name,
  2. mailing address,
  3. telephone number,
  4. a signed, written authorization from the person with Medicare stating that the representative can act on his/her behalf.

The appeal request must also include:

  1. the title of the LCD that is being challenged,
  2. the specific provision(s) of the LCD affecting the person with Medicare, and
  3. the name of the private company (Carrier or FI) that used the LCD.

In addition to this, the request should explain:

  1. what item or service is needed,
  2. why the LCD is incorrect and
  3. why the appeal request is being made.

With the LCD appeal request, send a written statement from the doctor treating you that states that the item or service is needed, along with any clinical or scientific information that supports why the LCD should be revised or no longer used.

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