CMS Issues Final Rules on Medicare Coverage Appeals

At long last, Medicare beneficiaries have two different methods of challenging coverage denials. In addition to the traditional administrative process, beneficiaries denied coverage may now challenge either the National Coverage Determination (NCD) or the Local Coverage Determination (LCD) on which the denial was based. This is as a result of final rules published by the Centers for Medicare & Medicaid Services (CMS) on appeals from Medicare Coverage Determinations. 68 Fed. Reg. 63692 (Nov. 7, 2003).

The rules were mandated by Congress as part of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). See ElderLawAnswers news item, "CMS Proposes Rule for Appealing Medicare Determinations", Aug. 29, 2002

Section 522 of the BIPA created a new review process that enables certain beneficiaries to challenge NCDs and LCDs. NCDs are developed by CMS and govern which items and services will be covered for all Medicare beneficiaries. LCDs are developed by the 'carriers' contracting with CMS to review Medicare claims and are applicable only within the region in which the particular entity is operating.

The new appeal rights are distinct from the existing appeal rights for the adjudication of Medicare claims. Review of an LCD or NCD requires examination of an entire policy, or specific provisions contained therein, and not just one claim denial. Before BIPA, the statute did not provide an administrative avenue to challenge the facial validity of LCDs or NCDs.

The provisions in the final rule are effective December 8, 2003.

For the final rules, go to and scroll down to Health and Human Services and then click on Centers for Medicare & Medicaid.

For the text version of the new rules, click here.