US · guidance
CMS Pub. 100-08, ch. 13, § 13.4
Challenge of an LCD
In addition to creating the term “Local Coverage Determination” (LCD), section 1869(f) of the
Social Security Act creates an appeals process for an “aggrieved party” to challenge
LCDs/LCD provisions that are in effect at the time of the challenge. “Aggrieved party” is
defined in regulation as a Medicare beneficiary, or the estate of a Medicare beneficiary, who is
entitled to benefits under Part A, enrolled under Part B, or both (including an individual
enrolled in fee-for-service Medicare, in a Medicare Advantage plan (MA), or in another
Medicare managed care plan), and is in need of coverage for an item or service that would be
denied by an LCD, as documented by the beneficiary’s treating physician, regardless of whether
the service has been received. An aggrieved party has obtained documentation of the need by
the beneficiary’s treating physician.
Contractors shall follow all LCD Challenge requirements outlined in 42 CFR part 426. As
indicated in 42 CFR § 426.415 if appropriate, CMS may choose to participate as a party in the
LCD Challenge process.
History
(Rev. 863; Issued: 02-12-19; Effective: 10-03-18; Implementation: 01-08-19)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
8f2966a4764af0c13f87c5b4ed2ae7223dd8dd69c149dbff93353895f1d5bf14
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.