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Medicare and local coverage determinations explained

Medicare local coverage determinations and Medicare administrative contractors can be confusing, so here’s how they work.

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Medicare has a lot of different pieces to it, and it can get overwhelming or confusing at times.

One of the confusing terms many may not have heard of is “local coverage determination” or LCDS.

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A local coverage determination is the decision on whether the healthcare will provide something locally.

This could be a service or an item.

The Medicare administrative contractor makes this decision.

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The decision is made in accordance with section 1862(a)(1)(A) of the Social Security Act.

MACs develop LCDs and process claims.

What may be permissible in one city might not be in another, according to MACs.

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You may file an appeal if you feel the decision is unfair and you have Medicare benefits under Parts A and/or B.

You have 6 months to file the appeal from the date of your doctor writing a note saying you need it.

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