The CAP has repeatedly appealed to the Centers for Medicare and Medicaid Services (CMS) to remedy significant issues with the local coverage determination (LCD) decision-making process. An LCD is a decision made by a Medicare Administrative Contractor (MAC) on whether a particular service or item is reasonable and necessary, and therefore covered by Medicare within the specific jurisdiction that the MAC oversees. MACs are Medicare contractors that develop LCDs and process Medicare claims. The CAP believes that the elements critical to ensuring sound local coverage policy have been compromised as a result of CMS’ October 2018 revisions to the LCD guidelines. In a February 23 letter to the CMS, the CAP recommended the following:

• MACs take a more aggregate view of LCD development including published evidence as well as clinical expertise that physician CAC representatives have to offer.
• The CMS requires MAC open meetings to provide a more open forum for information exchange between MACs and stakeholders on new or revised LCDs and establish a minimum period of three weeks between posting an open meeting notice and date of the meeting.
• MACs be required to issue a final LCD on valid reconsideration requests within 180 days from the date the public comment period ends and MACs post a tracking sheet to their website with timely disclosure of information appropriate to reconsideration requests.
• The CMS require new Local Coverage Articles (LCA) or coding updates to existing LCAs that reflect non-routine changes in coding and that impact coverage, are subject to public notice and comment before new or revised LCAs take effect.
• The CMS adds key LCD process measures to the current MAC performance metrics to assess performance effectiveness and adherence to specific LCD guidelines and as outlined in MAC contracts.

The CAP will continue to engage with the CMS on important issues related to Medicare LCD reform. Visit the CMS’ Local Coverage Determination Process & Timeline for more information.