September 2002

CMS Proposes Appeals Process For
Medicare Coverage Decisions

Washington, D.C. - The Centers for Medicare & Medicaid Services proposed a rule recently that would establish a process for beneficiaries to appeal local or national Medicare coverage determinations. The proposed rule provides for independent review of these coverage policies.

Under the proposal, appeals of local coverage determinations would be reviewed initially by an administrative law judge. Appeals from national coverage determinations and from ALJ decisions on LCDs would be reviewed by the U.S. Department of Health & Human Services Departmental Appeals Board. The board’s decisions could be appealed to federal court.

The proposed rule is a first step toward formal implementation of several provisions of Section 522 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000.

Beneficiaries already have the right to appeal individual claims denials when they believe a covered item or service was denied improperly. The proposed rule would give them an additional avenue to challenge the underlying coverage policy. Decisions in these appeals may have implications for future Medicare coverage of the item or service for all Medicare beneficiaries, not just the individual who filed the appeal.

CMS has already implemented a process for any interested party to follow when seeking a change in a national coverage determination. More recently, it has instructed the private insurers that process Medicare claims for CMS to establish and publicize a process, to become effective Oct. 1, for certain interested parties to use to seek reconsideration of a local medical review policy. This is in addition to the process outlined in the proposed rule.

The proposed rule was published in the Aug. 22 “Federal Register.” CMS will accept public comments on the proposed rule until Oct. 21, and plans to publish a final rule as soon as possible after the public comment period is completed.

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