CMS tells its MACs not to write LCDs that simply replicate coverage rules already in LCDs. In part, this is because administrative law judges can over-ride language found in LCDs, but can't override language found in NCDs. It's confusing to the ALJ (and causes errors) if he thinks he can override language in an LCD, but it's actually quotation from some obscure source that he is forbidden to override.
Two offenders are at the top of the "New Draft LCD" report at CMS.
Redundant LCD for Bone Mass
Palmetto LCD DL39268 is for "bone mass measurement" and does virtually nothing but replicate language already in the NCD (and its claims manual instructions) for bone mass measurement. While they do put the benefit manual and claims manual citations in the header section, the body of the LCD is almost wholesale plagiarism from those existing sources and you can't really tell that.
Palmetto then goes on with a "summary of the evidence" for BMM, quoting USPSTF and so on, but this is wholly unnecessary, because the LCD is simply restating NCD level and statutory- and regulatory-level text - laws and regulations that define coverage for BMM. See SSA 1861(rr) and 42 CFR 410.31.
If in fact MACs are far behind and backlogged with LCD work, efforts like this seem like a pure unfiltered waste of time. Comments open to May 14.
LCD for Stem Cell Transplants
And another one. Also from Palmetto, LCD DL39270 covers allogeneic stem cell transplants for B and T cell Hodgkin's and Non-Hodgkin's lymphoma. Again, this is an area covered by an NCD. While the text states, "this policy describes locally covered indications," it doesn't do so very clearly.
The format for the LCD is standardized by CMS: "Coverage Indications and Limitations," followed by "Summary of Evidence," and "Analysis of Evidence."
Sounds simple, but, nope. Here, the coverage section merely repeats the NCD coverage, and then states, this LCD will cover additional indications. And abruptly, with that remark, the coverage section stops cold.
The LCD goes on to discuss "summary of evidence" and "analysis of evidence" but this isn't where the statements of covered and non covered criteria go, they belonged in the section labeled "indications and limitations for coverage."
The "summary of evidence" is supposed to be an objective description of published evidence, but it is not. It makes some broad statements and re-quotes the NCD again, which is not "a summary of the evidence" at all.
Then the jumps to "analysis of the evidence" (where you draw conclusions and asses the pro's and con's of the evidence against the need for coverage) and if anything, that reads more like a dry "summary of the evidence."
To convey this idea, for comparison, a medical record may have a "summary" of the patient which is what you see (fever, clouded chest x-ray, hacking cough, O2 sat of 85%, and household COVID exposure) and an "analysis" which is what that evidence makes you think (the patient has pneumonia and merits admission due to severity.)
In short, despite CMS providing a simple template, the LCD is confusing and has a willy-nilly disregard for the several headers and their expected content. Comments open to May 14.
