Medicare LCD: How Do Local Coverage Determinations Work? | Marca

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US NEWSUS NewsMedicare LCD: How do local coverage determinations work?

Here's what you need to know about Local Coverage Determinations (LCD) and Medicare Administrative Contractors (MAC).

Medicare LCD: How do local coverage determinations work?
Medicare LCD: How do local coverage determinations work?
  • SAM
Actualizado 09/04/2022 - 06:04 CDT
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When it comes to Medicare, there are so many new terms and words that it can be difficult to navigate the system and get the best health care and price. One of the terms that forms part of the Medicare vocabulary is Local Coverage Determination (LCD) and here, in this guide to Medicare LCDs, we'll break down all you need to know.

What is a Medicare LCD?

Let's start with the term itself. A Local Coverage Determination refers to the decision on whether or not to provide a particular service or item locally, in a certain region.

"LCDs are decisions made by a Medicare Administrative Contractor (MAC) on 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," the official Medicare website explains. "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."

Therefore, a Medicare LCD could determine whether or not you can get what you need and the decision might be different in your city compared to another in a different part of the USA.

Can you challenge a Medicare LCD?

If you're not happy with the result of a Local Coverage Determination, you do have the right to file an appeal if you require the item or service that isn't covered by the LCD and if you're entitled to benefits under Medicare Part A (Hospital Insurance), are enrolled under Medicare Part B (Medical Insurance), or both.

If you haven't yet had the item or service, you have six months to file your appeal from the date of the doctor's written note about needing that item or service.

However, if the item or service has already been purchased or had, you only have four months from the date of the initial denial notice from the MAC that used the LCD.

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Tag » What Is Local Coverage Determination