How can we get a MAC to update an LCD?

Q: Last week you talked about the MAC editing for medically necessary services related to the local coverage determination (LCD). What do we do if we have a situation where we believe that the list of covered diagnoses is not complete? How do we get our MAC to consider that information? We placed a call, but nothing has happened and we’ve received no response.

A: This is a great question and a very important one. There are two ways to accomplish this.

When a new LCD is in the draft stage, the MACs typically post them on their website and send the information through their listserv (If you are not on the listserv for your MAC, visit their website and sign up–it is free and full of information). During the draft period, they request and encourage providers to comment. They need assistance from providers, as they are not on the frontlines and the determination is written based on the information they have. This is the best opportunity to have an impact, as it occurs before the LCD becomes final.

Once an LCD is final, there are always things that occur in the regular course of medicine that open an LCD up to being incomplete. Each MAC has a formal process published on their website for “reconsideration requests.” This process is for finalized LCDs only and can relate to a specific section of the LCD or to the entire LCD. The reconsideration must include supporting evidence on why the submitter is challenging the LCD–so you must defend your policy challenge by providing published authoritative evidence, support that something has become a standard of practice, etc.

Check your MAC’s website for their specific process and requirements. Typically, the requirement is a letter along with supporting information, but depending on the scenario, some MACs may accept electronic communication.

It is important for providers to do their due diligence and read the drafts before they are finalized, as well as getting mistakes corrected and updates accomplished.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.