LICENSES AND NOTICES

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


Corporate

Print | Bookmark | Email | Font Size: + |

LCD Reconsideration Process

Note:  This process is for the reconsideration of a local coverage determination (LCD), not individual claims.

The Local Coverage Determination (LCD) Reconsideration process is a method by which interested parties can request a revision to an active LCD.  CGS follows the Centers for Medicare & Medicaid Services (CMS) Program Integrity Manual(Internet-only Manual 100-08), Chapter 13 process for LCD Reconsiderations. The reconsideration process is available for final, effective LCDs only. The entire LCD or any part of it is subject to reconsideration.  The process for LCD Reconsideration is outlined below.

Informal teleconference and LCD Reconsideration forms coming soon.

Informal Teleconference (Optional)

Prior to submitting a formal LCD Reconsideration, the requestor may request an informal call to review the requirements for a valid LCD Reconsideration request. A request for a conference call may be submitted via email to CMD.inquiry@cgsadmin.com. In the request for an informal discussion, requestors should include the following information:

  1. Include in the subject line of the email: "Request for LCD Reconsideration Call – [Title of LCD]"
  2. Several options for dates and times for a 30 minute conference call
  3. Teleconference number with enough lines to accommodate 15 participants
  4. Agenda for the call, including requestor participants and titles
  5. Summary information (1-2 paragraphs, maximum) for the reconsideration request.

Request Submission Criteria (Required)

CGS will consider all LCD reconsideration requests from:

  • Beneficiaries residing or receiving care in our contractor's jurisdiction; and
  • Providers doing business in our contractor's jurisdiction.
  • Any interested party doing business in our contractor's jurisdiction

Reconsideration requests are only accepted for LCDs published in final form.  Requests will not be accepted for other documents including:

  • National coverage Decisions (NCD);
  • Coverage provisions in interpretive manuals;
  • Proposed LCDs;
  • Template LCDs, unless or until they are adopted by the contractor;
  • Retired LCDs;
  • Individual claim determinations;
  • Bulletins, articles, training materials; and
  • Any instance in which no LCD exists, i.e., requests for development of an LCD.

CGS has the discretion to consolidate valid requests if similar requests are received. Any request for LCD reconsideration that, in the judgment of the contractor, does not meet these criteria is invalid.

CGS may revise or retire their LCDs at any time on their own initiatives.

If modification of the final LCD would conflict with an NCD, the request will not be valid. For information about the NCD reconsideration process, reference http://www.cms.gov/DeterminationProcess/01_overview.asp#regsExternal Website. Information about requesting an NCD or an NCD revision is found under "How to Request an NCD" in the Coverage Process section.

Should the requestor continue with a formal LCD Reconsideration request, a valid request must include the following:

  1. The specific language that the requestor proposes added to or deleted from an LCD; and,
  2. Justification for the proposed change supported by new evidence in the medical literature which will materially affect the LCDs content or basis.  Electronic copies of published (i.e., not embargoed), English language, full-text articles are required.

The level of evidence required for LCD reconsideration is the same as that required for new/revised LCD development (see Program Integrity Manual, Chapter 13).

How To Submit Request:

LCD reconsideration requests may be sent via one of three methods: email, hard copy by mail, or fax. Below lists pertinent information for each of the three methods:

  1. Email : CMD.INQUIRY@cgsadmin.com
    • Electronic requests should be sent with "LCD Reconsideration Request – [Name of LCD]" in the subject line.
    • If the attachment size for clinical citations exceeds 15 MB, the requestor must send the articles and supporting documents via multiple, smaller emails.
    • Please contact CMD.INQUIRY@cgsadmin.com for alternative methods for submitting large electronic files or if you have difficulty submitting an LCD Reconsideration request.
  2. Fax: 615.664.5971
    • Please address your fax cover sheet to J15 LCD Reconsideration – Attn: Chief Medical Director
    • Note: This fax line for the LCD reconsideration process described above. 
  3. Mail:

    CGS Administrators
    Attn: Chief Medical Director
    J15 A/B MAC LCD Reconsideration
    26 Century Blvd Ste ST610
    Nashville, TN 37214-3685

    Please note that this information is forJ15 MAC LCD reconsiderations only.

Next Steps

CGS will review materials received within 60 calendar days upon receipt and determine whether the request is valid or invalid.  If the request is invalid CGS will respond, in writing, to the requestor explaining why the request was invalid. 

A valid request response does not convey that a determination has been made whether or not the item or service will be covered or non-covered under 1862 (a)(1)(A) of the Act. The response to the requestor that the request is valid is simply an acknowledgement to the requestor of the receipt of a complete, valid request.

If the request is valid, the J15 will follow the process for LCD reconsiderations detailed in the Centers for Medicare & Medicaid Services (CMS) Program Integrity Manual (Internet-only manual 100-08), Chapter 13.  Once the submitted material is reviewed, you will be contacted should the CMDs have additional questions. If there are no additional questions from the CMDs, you should monitor the J15 MAC web sites and listservs for the posting of a proposed LCD, date and time for a public meeting and timeline for completion of your reconsideration request.  This information can be found under the Local Coverage Determinations link on the J15 Part A, B, and HHH web site- Medical Policies.

CGS will post updates to the LCD Summary Sheet on the Medicare Coverage Database web siteExternal Website.  Final LCDs will be finalized or retired within a rolling calendar year of publication date on the Medicare Coverage Database (365 days).

Related Information

Updated 07.21.20

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved