Local Coverage Determinations (LCD) challenge

What’s a "Local Coverage Determination" (LCD)?

LCDs are decisions made by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service in a MAC’s jurisdiction (region) in accordance with section 1862(a)(1)(A) of the Social Security Act. MACs are Medicare contractors that develop LCDs and process Medicare claims. The MAC’s decision is based on whether the service or item is considered reasonable and necessary.

Can I challenge an LCD?

You can challenge an LCD if both of these apply:

  • You’re entitled to benefits under Medicare Part A (Hospital Insurance) , are enrolled under Medicare Part B (Medical Insurance) , or both.
  • You need the item(s) or service(s) determined not covered by the LCD.

When can I file an LCD challenge?

  • If you haven’t gotten the item or service, you must file your request within 6 months of the date of the treating doctor's written statement that you need to get that item or service.
  • If you’ve already gotten the item or service, you must file your request within 120 days of the date of the initial denial notice from the MAC 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 doesn’t cover a certain item or service. This is because that item or service isn’t considered 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 I file an LCD challenge?

Send your LCD challenge to:

Department of Health & Human Services
Departmental Appeals Board, MS 6132
Civil Remedies Division
330 Independence Ave., S.W.
Cohen Building, Room G-644
Washington, DC 20201

What should I include in my LCD challenge?

  • Your name (the person with Medicare)
  • Your mailing address
  • Your state of residence, if different from your mailing address
  • Your phone number
  • The health insurance claim number, if you have one
  • Your email address, if you have one
  • The title of the LCD that you’re challenging
  • The specific provision(s) of the LCD affecting you
  • The name of the MAC that developed the LCD
  • A statement to explain:
    • What item or service you need
    • Why the LCD is incorrect
    • Why you’re challenging the LCD
  • A written statement from the doctor treating you explaining that you need the item or service. The statement should include any clinical or scientific information that supports why the LCD should be revised or no longer used.

If you’ve designated an authorized representative, include:

  • The representative’s:
    • Full name
    • Mailing address
    • Phone number
    • Email address, if he or she has one
  • A signed, written authorization stating that the representative can act on your behalf. Get this form in Spanish.