Local Medical Review Policy (LMRP) Development
Medical review decisions are made in accordance with both national and local policies. These policies are the foundation of the review process. LMRP is a formal statement developed through a specific process that:
* Defines the service
* Provides information about when a service is considered reasonable and necessary
* Outlines any coverage criteria and/or specific documentation requirements
* Provides specific coding and/or modifier information
* Provides references upon which the policy is based
Once developed and implemented, LMRPs provide the decision-making criteria for claim review and payment decisions. LMRPs are developed using input provided through an advisory committee of medical professionals both within the Medicare Program and the medical community. This process also allows for other medical professionals throughout the state to comment on proposed policies prior to finalization, thus assuring an objective review of the policy.
LMRPs are developed through the following process:
* Carriers develop LMRP in response to:
1. The absence of a national policy
2. The need to apply a national (CMS) policy
3. The advent of new technology
4. Data analysis indicating the need for LMRP
* Draft LMRP is presented and reviewed at meetings by the Carrier Advisory Committee (CAC), which is a committee of beneficiaries, physicians who have been nominated by their respective specialty associations, the carrier ’ s medical director, and other staff representatives of Medicare.
* Draft LMRPs are available on the carrier ’ s Web site. The physician community has an opportunity to provide input to the contractor ’ s Medical Policy Department regarding the drafted LMRP.
* Draft LMRPs are published and after a 45-day comment period, Carriers review comments and develop the final LMRP.
* Final LMRP is published on the carriers ’ Web site, at www.lmrp.net on the Internet, and is available in hardcopy by request.
* Implementation occurs at least 30 days after physician notification
Local Medical Review Policy (LMRP) Reconsideration Process –
Contractors who have the task of developing LMRPs must have an LMRP Reconsideration Process in accordance with the following instructions.
A – Purpose
The LMRP Reconsideration Process is a mechanism by which interested parties can request a revision to an LMRP.
B – Scope
The LMRP Reconsideration Process is available only for final LMRPs. The whole LMRP or any part of the LMRP may be reconsidered, i.e., Benefit Category Provisions,
Utilization Guidelines,Covered ICD-9 codes, etc.
C – General
Contractors must respond timely to requests for LMRP reconsideration. In addition, contractors may revise or retire their LMRPs at any time on their own initiatives. When a contractor receives a request for policy review that mentions §1869(f) of thE Social Security Act, the contractor must follow the instructions in CMS Ruling 01-01. The contractor may also choose to initiate an LMRP reconsideration following the process in this PIM section.
D – Website Requirements for the LMRP Reconsideration Process
Contractors must add to their current web sites information on the LMRP Reconsideration Process. This information may be on the home page or linked to another location. It must be labeled “LMRP Reconsideration Process” and must include:
• A description of the LMRP Reconsideration Process; and
• Instructions for submitting LMRP reconsideration requests, including postal, e-mail, and fax addresses where requests may be submitted.
E – Valid LMRP Reconsideration Request Requirements
1. Contractors:
a. MUST consider all LMRP reconsideration requests from:
• Beneficiaries residing or receiving care in a contractor’s jurisdiction; and
• Providers doing business in a contractor’s jurisdiction.
b. MAY consider LMRP reconsideration requests from any interested party doing business in a contractor’s jurisdiction.
2. Contractors may only accept reconsideration requests for LMRPs published in final form. Requests must not be accepted for other documents including:
• National Coverage Decisions (NCD);
• Coverage provisions in interpretive manuals;
• Draft LMRPs;
• Template LMRPs, unless or until they are adopted by the contractor;
• Retired LMRPs;
• Individual claim determinations;
• Bulletins, articles, training materials; and
• Any instance in which no LMRP exists, i.e., requests for development of an LMRP.
If modification of the LMRP would conflict with an NCD, the request would not be valid.
The contractor should refer the requestor to the NCD reconsideration process (www.cms.hhs.gov/coverage/Ba1.htm).
3. Requests must be submitted in writing, and must identify the language that the requestor wants added to or deleted from an LMRP. Requests must include a justification supported by new evidence, which may materially affect the LMRP’s content or basis. Copies of published evidence must be included.
The level of evidence required for LMRP reconsideration is the same as that is required for new/revised LMRP development. (PIM Chapter 13, Section 7.1)
4. Any request for LMRP reconsideration that, in the judgment of the contractor, does not meet these criteria is invalid.
5. Contractors may consolidate valid requests if similar requests are received.
F – Process
1. The requestor should submit a valid LMRP reconsideration request to the appropriate contractor, following instructions on the contractor’s web site.
2. Within 30 days of the day the request is received, the contractor must determine whether the request is valid or invalid. If the request is invalid, the contractor must respond, in writing, to the requestor explaining why the request was invalid. If the request is valid, the contractor should follow the requirements below.
3. Within 90 days of the day the request was received, the contractor must make a final LMRP reconsideration decision on the valid request and notify the requestor of the decision with its rationale. Decision options include retiring the policy, no revision, revision to a more restrictive policy, or revision to a less restrictive policy.
4. If the decision is either to retire the LMRP or to make no revision to the LMRP, then within 90 days of the day the request was received, the contractor must inform the requestor of that decision with its rationale.
5. If the decision is to revise the LMRP, follow the normal process for LMRP development.
6. Contractors must keep an internal list of the LMRP Reconsideration Requests received and the relevant dates, subject, and disposition of each one.
More Info
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R44PI.pdf
