Ever heard of a Local Coverage Determination (LCD)? An LCD is a determination by a Medicare Administrative Contractor (MAC) regarding whether a contractor covers a particular item or service. We encourage each state chapter president to appoint Contractor Advisory Committee (CAC) representatives and alternates in diagnostic radiology, radiation oncology, interventional radiology, and nuclear medicine to participate in the development of LCD policies and to review existing policies. These representatives might also seek clarification and suggest updates as clinical practice evolves. In addition, CAC Network members provide valuable feedback to their chapters and the ACR on problems at the local level and disseminate information back to their chapters on updates to Medicare policies.
Prior to 2019, each MAC held meetings three times a year with primary care and specialty representatives of the CAC to start its review of draft LCDs. Before the LCDs were finalized, the CAC members made suggestions for revision based on scientific data and published literature. However, in 2019, Congress passed the 21st Century Cures Act aimed at improving the process of LCD development and decreasing regional variation in policies.
The restructured CAC meetings are now open to the public. CAC members serve in an advisory capacity as representatives of their constituency to review the quality of the evidence used in the development of an LCD. MACs can host CAC meetings in several ways (in-person, telephone, video, webinar). MACs determine how frequently these meetings occur based on the appropriateness and volume of LCDs requiring CAC input. MACs have the option of hosting CAC meetings prior to the posting of a proposed LCD to assist in the upfront analysis of the evidence or after the publication of the proposed LCD. MACs now also have the option of organizing meetings with CAC members of multiple jurisdictions convening at one time. In addition to physicians, other healthcare professionals (e.g., nurses, social workers, epidemiologists) can participate in the CAC. The CAC must also include Medicare beneficiary representation.
What is the difference between National Coverage Determination (NCD) and LCD policies? Medicare coverage is limited to items and services that are “reasonable and necessary” for the diagnosis or treatment of an illness or injury. NCDs are made through an evidence-based process with opportunities for public participation. In some cases, CMS research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development and Coverage Advisory Committee to provide comments regarding specific clinical and scientific issues in an open and public forum (although CMS makes the final decision on coverage issues). NCDs are binding on all Medicare contractors, quality improvement organizations, health maintenance organizations, competitive medical plans, and healthcare prepayment plans.
In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on an LCD. It turns out that 90% of Medicare policies are established at the local level, providing contractors with tremendous authority over payment policy in each state. However, the ACR CAC Network is concerned about recent changes in the LCD development process — particularly with the lack of transparency and consistency, the lack of compulsory CAC meetings in states/jurisdictions, and the removal of CAC member input into proposed LCDs prior to final policy release. Recently, the ACR joined other specialty organizations to send a letter to CMS to share our concerns and make recommendations to improve the LCD development process. Regardless of what CMS decides to do, members of the ACR CAC Network continue to play a critical role in the LCD development process and other proposed policy changes.