A local coverage determination (LCD) is a decision by a Medicare Administrative Contractor (MAC) regarding whether or not a particular item or service is covered on a contractor–wide basis.

Section §1869(f)(2)(B) of the Social Security Act (SSA), established LCDs.

The 21st Century Cures Act of 2016 added language to section 1862(l)(5)(D) of the SSA directing the Secretary of the Department of Health and Human Services to improve the transparency of the LCD process.¹

Through engagement with stakeholders Medicare ascertained how to reduce administrative burden and improve the program, the resulting LCD process changes work to provide greater transparency, consistency and patient engagement.²

The LCD process may begin with informal meetings in which interested parties in the MAC’s jurisdiction can informally discuss potential LCD requests. These meetings are permitted but are not required and the process allows requesters to communicate via conference call or in-person meeting before submitting a formal request. These meetings will assure that all relevant evidence needed for review for coverage is submitted with the request for a formal review.¹ 

Interested parties within a contractor’s jurisdiction can request a new LCD. Contractors consider all new LCD requests from: beneficiaries residing or receiving care in a contractor’s jurisdiction and health care professionals or any interested party doing business in a contractor’s jurisdiction.¹

Contractors shall consider New LCD Requests to be a complete if the request:

• Is in writing and sent to the MAC via e-mail, facsimile or written letter

• Clearly identifies the statutorily-defined Medicare benefit category, with rationale for the assignment

• Identifies the language that the requestor wants in an LCD

• Contains justification supported by peer-reviewed evidence 

• Include information that addresses the relevance, usefulness, clinical health outcomes, or the medical benefits of the item or service

• Includes information that fully explains the design, purpose, and/or method of using the item or service

The MAC will review materials received within 60 calendar days upon receipt and determine whether the request is complete or incomplete. If the request is incomplete, the contractor shall respond, in writing, to the requestor explaining why the request was incomplete.¹

If the request is complete, the MAC will follow this process:

1. Consultation with the requestor or subject matter experts (if necessary)

2. Open meeting to develop evidence on the proposed LCD (If necessary)

3. Publication of a proposed LCD

4. Contractor Advisory Committee meeting (if necessary)

5. Opportunity for public comment in writing (minimum of 45 days following posting of proposed LCD)

6. Publication of a final LCD³

90 percent of Medicare policies are established at the local level, providing contractors with tremendous authority over payment policy in a given state.⁴

A beneficiary or stakeholder in a MAC’s jurisdiction can request a revision to an LCD. The whole LCD or any provision of the final LCD may be reconsidered. In addition, MACs have the discretion to revise or retire their LCDs at any time on their own initiative.¹

1. United States Department of Health and Human Services. Medicare Program Integrity Manual Chapter 13 – Local Coverage Determinations. Centers for Medicare & Medicaid Services.

2. United States Department of Health and Human Services. Local Coverage Determination (LCD) Process Modernization Qs & As. Centers for Medicare & Medicaid Services.

3. Requests for New LCD. CGS Medicare. https://www.cgsmedicare.com/hhh/coverage/lcd_requests.html. Published 2020.

4. National and Local Coverage Determinations. Acr.org. https://www.acr.org/Advocacy-and-Economics/Radiology-Economics/Medicare-Medicaid/Coverage.