Ask the Experts: Relieving the Pain of Local Coverage Determinations - Webinar 13

In episode 13, our experts covered your questions on:

• How does the Centers for Medicare & Medicaid Services (CMS) determine coverage and procedural reimbursement?
• How are LCDs made?
• Who determines the evidence and eventual policy on LCD coverage?
• Are specialists involved in the LCD development and revision process? If yes, how can one become involved?
• Are there other documents besides LCDs necessary for CMS compliance?

Your expert panel for this April 17, 2025 webinar included:

• Meredith Loveless, MD, FACOG, of CGS Administrators where she serves the 48,500 physicians and 2 million Medicare beneficiaries in Kentucky and Ohio as the Chief Medical Officer for the J15 A/B MAC (Medicare Administrative Contractor); and
• W. David Mauck, MD, Chairman of the Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine at Mayo Clinic in Rochester, Minnesota, who also serves IPSIS members as Health Policy Division Chair.

The panel was moderated by Michael Furman, MD, MS, Fellowship Director at OSS Health, who serves on the IPSIS Board as a Member-at-Large, as well as on the IPSIS Education Division, and as Co-Chair of the Education Development Committee. Listen on the go — make "Ask the Experts" your new go-to podcast! Besides the video, an audio download is also available here.

Episode 13 Show Notes: These are the Medicare resources and references mentioned on the webinar. We also encourage you to get directly involved in this process. Contact IPSIS Health Policy Director Sarah Cartagena, MS for details.

• What is a MAC and MAC jurisdiction map?
  • What's a MAC | CMS
  • AB-Jurisdiction-Map_03.28.2023
• Local Coverage Determinations
  • Landing page- one stop for all MACs and link to the rules for LCDs
    • Local Coverage Determinations | CMS
  • Medicare Program Integrity Manual (LCD rule MACs must follow)
  • How do I find an LCD? MCD Search
  • LCD request or LCD reconsideration- this should be on your MACs website here is the links for CGS:
    • LCDs & Medical Policies
• Medicare Managed Care Manual Chapter 4 - Benefits and Beneficiary Protections sections 90 – 90.6
  • https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/mc86c04.pdf
  • Do Medicare Advantage Plans Follow CMS Guidelines? | Medicare & Medicare Advantage Info, Help and Enrollment
• How is coverage determined by Medicare?
  • Medicare Coverage Determination Process | CMS this discusses NCD’s as well
  • Article on how evidence is used (CGS): Principles of Study Design
  • How evidence is used published by CMS: CMS National Coverage Analysis Evidence Review
  • The definition of reasonable and necessary for Medicare coverage decisions:
    • Section 1862(2)(a) (1)(A) of the Social Security Act
      • The MAC will determine if an item or service is “reasonable and necessary" under Section 1862(2)(a) (1)(A) of the Act and if the service is:
        • Safe and effective;
        • Not experimental or investigational; and
        • Appropriate, including the duration and frequency in terms of whether the service or item is:
          • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the beneficiary’s condition or to improve the function of a malformed body member;
          • Furnished in a setting appropriate to the beneficiary’s medical needs and condition;
          • Ordered and furnished by qualified personnel; and
          • One that meets, but does not exceed, the beneficiary’s medical need
  • Top 10 ways providers can impact the LCD process:
    1. LCD request/reconsiderations.
    2. Research! Producing high quality literature to answer questions in evidence-based way.
    3. Sharing pertinent literature with your MAC.
    4. Serving as CAC member or as subject matter expert.
    5. Participating in societies / providing input for societies.
    6. Societies/panels to produce evidence-based guidelines – encourage use of GRADE or systematic evidence review process.
    7. Present at open meeting or submit comments if concerns – back it up with evidence.
    8. Full disclosure of potential bias.
    9. Understand that we are fulfilling requirements determined by law when we follow the policy process.
    10. Participate in education.

© 2025 International Pain and Spine Intervention Society – All Rights Reserved Materials presented in this activity have been made available by the International Pain and Spine Intervention Society for educational purposes only.