#aae? ,,congress  #b;d ,session  ,h4 ,r4
 #cfce  ,,an ,,act  ,to am5d title      
,,xviii ( ! ,social ,security ,act 9    
ord] to improve ! process :]eby m$ic>e  
adm9i/rative contractors issue local    
cov]age det]m9ations "u ! ,m$ic>e       
program1 & = o!r purposes4  #a4 ,%ort   
title ,?is ,act may be cit$ z ! ,local  
,cov]age ,det]m9ation ,cl>ification ,act
 ( #bjah4  #b4 ,improvem5ts 9 ! ,m$ic>e 
local cov]age det]m9ation 7,,lcd7       
process = specifi$ ,l,c,ds  7a7         
,developm5t process = specifi$ ,l,c,ds  
,section #ahfb7l77#e77;,d7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           
#aciey7l77#e77;,d77 is am5d$ to read z  
foll[s3  7,d7 ,process = issu+ specifi$ 
local cov]age det]m9ations  7i7 ,9 g5]al
 ,9 ! case ( a specifi$ local cov]age   
det]m9ation 7z def9$ 9 clause 7iii77 )9 
an area by a m$ic>e adm9i/rative        
contractor1 su* m$ic>e adm9i/rative     
contractor mu/ take ! foll[+ actions )  
respect to su* det]m9ation be=e su*     
det]m9ation may take effect3 7,i7       

,publi% on ! public ,int]net website ( !
 int]m$i>y or c>ri] a propos$ v]sion ( !
 specifi$ local cov]age det]m9ation 79  
?is subp>agraph ref]r$ to z a draft     
det]m9ation71 a writt5 rationale = !    
draft det]m9ation1 & a description ( all
 evid5ce reli$ ^u & consid]$ by !       
int]m$i>y or c>ri] 9 ! developm5t ( !   
draft det]m9ation4  7,,ii7 ,n lat] ?an  
#fj days aft] ! date on :i* ! int]m$i>y 
or c>ri] publi%es ! draft det]m9ation 9 
accordance ) subclause 7,i71 conv5e "o  
or m op51 public meet+s to review !     
draft det]m9ation1 receive comm5ts )    
respect to ! draft det]m9ation1 & secure
 ! advice ( an exp]t panel 7su* z a     
c>ri] advisory committee describ$ 9     
*apt] #ac ( ! ,m$ic>e ,program          
,integrity ,manual 9 effect on ,augu/   
#ca1 #bjae7 ) respect to ! draft        
det]m9ation4 ,! int]m$i>y or c>ri] %all 
make available means = ! public to att5d
 su* meet+s remotely1 su* z via         
teleconf]5ce4  7,,iii7 ,) respect to ea*
 meet+ conv5$ pursuant to subclause     

7,,ii71 po/ on ! public ,int]net website
 ( ! int]m$i>y or c>ri]1 n lat] ?an #ad 
days aft] su* meet+ is conv5$1 a record 
( ! m9utes = su* meet+1 :i* may be a    
record+ ( ! meet+4  7,,iv7 ,provide a   
p]iod = submission ( writt5 public      
comm5t on su* draft det]m9ation t beg9s 
on ! date on :i* all records requir$ to 
be po/$ ) respect to su* draft          
det]m9ation "u subclause 7,,iii7 are s  
po/$ & t is n few] ?an #cj days 9       
duration4  7ii7 ,f9aliz+ a specifi$     
local cov]age det]m9ation ,a fiscal     
int]m$i>y or c>ri] t has ent]$ into a   
contract ) ! ,secret>y "u section       
#ahgd;,a %all1 ) respect to a specifi$  
local cov]age det]m9ation1 po/ on !     
public ,int]net website ( ! fiscal      
int]m$i>y or c>ri] ! foll[+ in=mation   
be=e ! specifi$ local cov]age           
det]m9ation 79 ?is subp>agraph ref]r$ to
 z ! f9al det]m9ation7 takes effect--   
7,i7 a response to ! relevant issues    
rais$ at meet+s conv5$ pursuant to      
clause 7i77,,ii7 ) respect to ! draft   

det]m9ation2  7,,ii7 ! rationale = !    
f9al det]m9ation2  7,,iii7 9 ! case t ! 
int]m$i>y or c>ri] consid]$ qualify+    
evid5ce 7z def9$ 9 clause 7v77 t 0 n    
describ$ 9 ! writt5 notice provid$      
pursuant to clause 7i77,i71 a           
description ( su* qualify+ evid5ce2 &   
7,,iv7 an effective date = ! f9al       
det]m9ation t is n less ?an #cj days    
aft] ! date on :i* su* det]m9ation is s 
po/$4  7iii7 ,specifi$ local cov]age    
det]m9ation def9$ ,= purposes ( ?is     
subp>agraph1 ! t]m specifi$ local       
cov]age det]m9ation means1 ) respect to 
! relevant geographic area-- 7,i7 a new 
local cov]age det]m9ation2  7,,ii7 a    
revis$ local cov]age det]m9ation = su*  
geographic area t re/ricts "o or m exi/+
 t]ms ( cov]age = su* area 7su* z by    
add+ requirem5t to an exi/+ local       
cov]age det]m9ation t results 9 decreas$
 cov]age or by delet+ previ\sly cov]$   
,,icd-#i or ,,icd-#aj codes 7= reasons  
o!r ?an r\t9e cod+ *anges772  7,,iii7 a 
revis$ local cov]age det]m9ation t makes

 a sub/antive revision to "o or m exi/+ 
local cov]age det]m9ations2 or  7,,iv7  
any o!r local cov]age det]m9ation       
specifi$ by ! ,secret>y pursuant to     
regulations4  7iv7 ,qualify+ evid5ce    
def9$ ,= purposes ( ?is subp>agraph1 !  
t]m qualify+ evid5ce means publicly     
available evid5ce ( g5]al acceptance by 
! m$ical community1 su* z publi%$       
orig9al rese>* 9 pe]-review$ m$ical     
j\rnals1 sy/ematic reviews &            
meta-analyses1 evid5ce-bas$ cons5sus    
/atem5ts1 & cl9ical guidel9es4  4  7b7  
,,lcd reconsid]ation process ,section   
#ahfi7;f7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #acie;ff7f77 is am5d$--  
7#a7 9 p>agraph 7#b77;,a71 by ins]t+    
7includ+ ! reconsid]ations describ$ 9   
p>agraphs 7#h7 & 7#i77 aft] local       
cov]age det]m9ation2  7#b7 9 p>agraph   
7#e71 by ins]t+ 7except = a             
reconsid]ation describ$ 9 p>agraphs 7#h7
 & 7#i77 aft] ! cov]age det]m9ation2    
7#c7 by r$esignat+ p>agraph 7#h7 z      
p>agraph 7#ac72 &  7#d7 by ins]t+ aft]  

p>agraph 7#g7 ! foll[+ new p>agraphs3   
7#h7 ,c>ri] or fiscal int]m$i>y         
reconsid]ation process = specifi$ local 
cov]age det]m9ations ,^u ! fil+ ( a     
reque/ by an int]e/$ p>ty 7z def9$ 9    
p>agraph 7#aa77;,b77) respect to a      
specifi$ local cov]age det]m9ation by a 
fiscal int]m$i>y or c>ri] t has ent]$   
into a contract ) ! ,secret>y "u section
 #ahgd;,a1 ! int]m$i>y or c>ri] %all    
reconsid] su* det]m9ation 9 accordance )
 ! foll[+ process3  7,a7 ,n lat] ?an #cj
 days aft] su* a reque/ is fil$ ) !     
fiscal int]m$i>y or c>ri] by ! int]e/$  
p>ty ) respect to su* det]m9ation1 !    
int]m$i>y or c>ri] %all-- 7i7 det]m9e   
:e!r ! reque/ is an applicable reque/2 &
  7ii7 9 ! case t ! reque/ is n an      
applicable reque/1 in=m ! int]e/$ p>ty (
 ! reasons :y su* reque/ is n an        
applicable reque/4  7,b7 ,9 ! case t !  
int]m$i>y or c>ri] det]m9es "u          
subp>agraph 7,a7 t ! reque/ describ$ 9  
su* subp>agraph is an applicable reque/1
 ! int]m$i>y or c>ri] %all1 n lat] ?an  

#ij days aft] ! date on :i* ! reque/ 0  
fil$ ) ! int]m$i>y or c>ri]1 take !     
actions describ$ 9 subp>agraphs 7,c71   
7,d71 & 7,e7 ) respect to ! det]m9ation4
  7,c7 ,! action describ$ 9 ?is         
subp>agraph is ! action ( specify+ :e!r 
any ( ! foll[+ /atem5ts is applicable to
 ! det]m9ation3 7i7 ,! det]m9ation did n
 reasonably consid] qualify+ evid5ce    
relevant to su* det]m9ation4  7ii7 ,!   
det]m9ation us$ language t exce$$ !     
scope ( ! int5d$ purpose ( !            
det]m9ation4  7iii7 ,! det]m9ation 0    
incorrect 9 its det]m9ation ( :e!r su*  
item or s]vice is reasonable & necess>y 
= ! diagnosis or treatm5t ( illness or  
injury "u section #ahfb7;a77#a77;,a74   
7iv7 ,! det]m9ation fail$ to describe1 )
 respect to su* an item or s]vice1 !    
cl9ical conditions to be us$ = purposes 
( det]m9+ :e!r su* item or s]vice is    
reasonable & necess>y = ! diagnosis or  
treatm5t ( illness or injury "u section 
#ahfb7;a77#a77;,a74  7v7 ,! det]m9ation 
does n apply ) respect to items or      

s]vices to :i* x 0 int5d$ to apply4     
7vi7 ,! det]m9ation is errone\s = ano!r 
reason t ! int]m$i>y or c>ri] id5tifies4
  7,d7 ,! action describ$ 9 ?is         
subp>agraph1 ) respect to ! det]m9ation1
 is ! action ( tak+1 bas$ on !          
specification "u subp>agraph 7,c7 ( :e!r
 any ( ! /atem5ts 9 su* subp>agraph     
appli$ to su* det]m9ation1 "o or m ( !  
foll[+ actions3  7i7 ,mak+ no *ange 9 ! 
det]m9ation4  7ii7 ,resc9d+ all or a "p 
( ! det]m9ation4  7iii7 ,modify+ !      
det]m9ation to re/rict ! cov]age provid$
 "u ?is title = an item or s]vice t is  
subject to ! det]m9ation4  7iv7 ,modify+
 ! det]m9ation to exp& ! cov]age provid$
 "u ?is title = an item or s]vice t is  
subject to ! det]m9ation4  7,e7 ,!      
action describ$ 9 ?is subp>agraph is !  
action ( mak+ publicly available a      
writt5 description ( ! action tak5 "u   
subp>agraph 7,d7 ) respect to !         
det]m9ation1 includ+ ! evid5ce consid]$ 
by ! m$ic>e adm9i/rative contractor4    
7#i7 ,ag5cy review ( reconsid]ation     

decision ,! ,secret>y %all e/abli% a    
process to review a m$ic>e adm9i/rative 
contractor's te*nical compliance ) !    
requirem5ts1 includ+ ensur+ t ! m$ic>e  
adm9i/rative contractor indep5d5tly     
review$ ! evid5ce involv$1 ( !          
reconsid]ation "u p>agraph 7#h74  7#aj7 
,rule ( con/ruction ,no?+ 9 p>agraph    
7#h7 may be con/ru$ z affect+ ! "r ( an 
aggriev$ p>ty to file a compla9t "u     
p>agraph 7#b77;,a7 & receive a          
det]m9ation 9 accordance ) ! provisions 
( su* p>agraph4 ,an aggriev$ p>ty is n  
requir$ to file a reque/ "u p>agraph    
7#h7 or 7#i7 prior to fil+ a compla9t "u
 p>agraph 7#b74  7#aa7 ,def9itions      
applicable to p>agraphs 7#h7 & 7#i7 ,=  
purposes ( p>agraphs 7#h7 & 7#i73  7,a7 
,! t]m applicable reque/ means a reque/ 
t is submitt$ 9 fiscal ye> #bjai or a   
subsequ5t fiscal ye>1 t is solely )     
respect to a specifi$ local cov]age     
det]m9ation1 & t includes a description 
( ! rationale = su* reque/ & any        
in=mation or evid5ce support+ su*       

reque/4 ,= purposes ( ! prec$+ s5t5ce1 !
 ,secret>y may n require1 z a condition 
( treat+ a reque/ ) respect to su* a    
det]m9ation z an applicable reque/1 t ! 
reque/ conta9 qualify+ evid5ce t 0 n    
consid]$ 9 ! developm5t ( su*           
det]m9ation4  7,b7 ,! t]m int]e/$ p>ty  
means1 ) respect to a specifi$ local    
cov]age det]m9ation )9 an area by a     
fiscal int]m$i>y or c>ri] t has ent]$   
into a contract ) ! ,secret>y "u section
 #ahgd;,a1 a b5efici>y or /akehold]     
7includ+ a m$ical pr(essional society or
 physician74  7,c7 ,! t]m qualify+      
evid5ce has ! mean+ giv5 su* t]m by     
clause 7iv7 ( section #ahfb7l77#e77;,d74
  7,d7 ,! t]m specifi$ local cov]age    
det]m9ation has ! mean+ giv5 su* t]m by 
clause 7iii7 ( su* section4  7#ab7      
,report ,n lat] ?an ,decemb] #ca ( ea*  
ye> 7beg9n+ ) #bjai71 ! ,secret>y %all  
submit to ,congress a report conta9+ !  
foll[+3 7,a7 ,! numb] ( reque/s fil$ )  
fiscal int]m$i>ies & c>ri]s "u p>agraph 
7#h71 & ! numb] ( appeals fil$ ) !      

,secret>y "u p>agraph 7#i71 dur+ !      
#a-ye> p]iod end+ on su* date4  7,b7 ,) 
respect to su* reque/s fil$ ) su*       
int]m$i>ies & c>ri]s "u p>agraph 7#h7   
dur+ su* p]iod1 ! numb] ( times t       
int]m$i>ies & c>ri]s took1 ) respect to 
! actions describ$ 9 subp>agraphs 7,c7  
?r\gh 7,e7 ( su* p>agraph1 ea* su*      
action4  7,c7 ,) respect to su* appeals 
fil$ ) ! ,secret>y "u p>agraph 7#i7 dur+
 su* p]iod1 ! numb] ( times t !         
,secret>y took1 ) respect to ! actions  
describ$ 9 subp>agraph 7,d7 ( p>agraph  
7#h71 ea* su* action4  7,d7             
,recomm5dations on ways to improve-- 7i7
 ! efficacy & ! effici5cy ( ! process   
describ$ 9 p>agraph 7#h72 &  7ii7       
communication ) individuals entitl$ to  
b5efits "u "p ,a or enroll$ "u "p ,b1   
provid]s ( s]vices1 & suppli]s reg>d+   
su* process4  4  #c4 ,promulgation (    
regulations2 application date ,!        
,secret>y ( ,heal? & ,human ,s]vices    
%all promulgate regulations to c>ry out 
p>agraph 7#e77;,d7 ( section #ahfb7l7 ( 

! ,social ,security ,act 7#db ,u4,s4,c4 
#aciey7l771 z am5d$ by subsection 7a71 &
 p>agraphs 7#h7 & 7#i7 ( section        
#ahfi7;f7 ( su* ,act 7#db ,u4,s4,c4     
#acie;ff7f771 z ins]t$ by subsection    
7b71 9 su* a mann] z to ensure t !      
processes describ$ 9 su* p>agraphs are  
fully implem5t$ by ,janu>y #a1 #bjbj4   
,pass$ ! ,h\se ( ,repres5tatives        
,septemb] #ab1 #bjah4;,cl]k4