CMS Allows Exceptions to Local Coverage Determinations


In certain circumstances, providers may receive payment for care that is otherwise precluded from coverage under a local coverage determination (LCD). The Centers for Medicare and Medicaid Services (CMS) has amended its Program Integrity Manual (PIM) to authorize Medicare contractors to create exceptions to LCDs during complex medical review. Transmittal No. 303 allows contractor medical directors (CMDs) to override LCDs and utilize clinical criteria to support or deny a claim. Recovery Audit Contractors (RACs) may utilize the LCD exception to allow a claim, but may not use it to deny a claim

that is otherwise covered under existing LCD guidance. Mark A. Stanley of Ober|Kaler discusses.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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