Each Fiscal Intermediary (FI) has the authority to produce their own “Local Coverage Determination” (LCD), based on national guidelines. The LCD basically defines under which circumstances a particular procedure is covered under the patient's Medicare benefits. As new procedures are developed, the FI will then set out to create an LCD. The FI will also review existing LCDs to see if changes are necessary based on treatment advances, statistical data, industry standards, etc.
How do LCDs affect you? If a procedure is planned, but the criteria of the LCD is not met, you will get a very swift denial, that turns into months of waiting for responses to appeals. If you are familiar with the parameters of the LCD, you may be able to avoid the denial or at least have the exact medical documentation needed that addresses the specific potential cause for denial. Most LCDs do contain the “Medically Necessary” clause. If your documentation can prove that the case is an “exception” to the rule and the procedure is medically necessary, you will likely be successful in your appeal.
The websites for all FIs include a search for LCDs. You can quickly and easily enter a CPT or HCPC code to get the most recent version of the LCD. Many times you can also enroll for automated email updates regarding new or changing LCDs. This also allows you to become involved in the creation/modification of the LCD, as the FI offers comment periods before making them active.
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