Challenge of an LCD

13.4 - Challenge of an LCD (Rev. 863; Issued: 02-12-19; Effective: 10-03-18; Implementation: 01-08-19) In addition to creating the term “Local Coverage Determination” (LCD), section 1869(f) of the Social Security Act creates an appeals process for an “aggrieved party” to challenge LCDs/LCD provisions that are in effect at the time of the challenge. “Aggrieved party” is defined in regulation as a Medicare beneficiary, or the estate of a Medicare beneficiary, who is entitled to benefits under Part A, enrolled under Part B, or both (including an individual enrolled in fee-for-service Medicare, in a Medicare Advantage plan (MA), or in another Medicare managed care plan), and is in need of coverage for an item or service that would be denied by an LCD, as documented by the beneficiary’s treating physician, regardless of whether the service has been received. An aggrieved party has obtained documentation of the need by the beneficiary’s treating physician. Contractors shall follow all LCD Challenge requirements outlined in 42 CFR part 426. As indicated in 42 CFR § 426.415 if appropriate, CMS may choose to participate as a party in the LCD Challenge process.