CAP and LCD Policy
College of American Pathologists has taken the point position, for years, on improving LCDs at Medicare. For example, some of their ideas were incorporated in 21st Century Cures, which passed during the Obama-Trump transition.
New News
April 28, CAP announces creation of H.R. 8500, "Timely Access to Coverage Decisions Act" (TACDA).
I'll cut and paste the CAP News below. You can also scroll for similar text about "8500" at this CAP page here. See a media quote from CAP here.
See also a Congressional press release here.
The actual legislation for HR 8500 is not posted online yet. Sponsor is Rep. Neal Dunn R FL, and cosponsors are Nanette Barragan D CA and Claudia Tenney R NY.
See also the "Issue Brief" link at bottom.
Sidebar: It's a Real Issue
MACs seem to be good at tiny revisions of old LCDs (e.g. "Cataracts.") MolDx is good at adding specific tests to a basket-size or foundational LCD (e.g. their Minimal Residual Disease LCD or their Comprehensive Genomic Profiling LCD.) But getting a small change in an existing MolDx LCD, or adding a new topic LCD at any MAC, is Waiting for Godot for years.
Sidebar: 21st Century Cures
MACs often say that "21st Century Cures" drastically slowed down LCD production. I can't believe it. 21st Century Cures had a very short section on LCDs, later incorporated into the CMS LCD manual chapter. 21st Century Cures required a public comment period, and a Q&A response that was issued with the final LCD. CMS already required that. 21st Century Cures requires posting a link to the draft LCD in the final LCD. That's can't possibly effection production. 21st Century Cures requires reviewing evidence in the LCD decision - that was also required before. 21st Century Cures says nothing about how long an LCD has to be - 2 citations seems too small, 200 seems too high, but 21st Century Cures (nor CMS) puts any requirements on length of bibliography.
One of the reasons for the evidence review requirement was to make it harder to simply autodeny things, like Category III codes, with no review and just a blanket statement like 'Cat III codes are not covered."
I've shown in earlier blogs that obtuse text in recent LCDs can be markedly improved and clarified by AI rewrites for clarity.
##### CAP SAYS: #####
Earlier this week, Representatives Dunn (R-FL), Tenney (R-NY), and Barragán (D-CA) introduced legislation addressing the issues with Local Coverage Determinations (LCD) known as the Timely Access to Coverage Decisions Act (H.R. 8500), and can be found here.
Local Coverage Determinations (LCDs) are developed by Medicare Administrative Contractors (MACs) and describe whether, and under what circumstances, a particular item or service receives coverage within a MAC geographic jurisdiction. Despite certain revisions to the Program Integrity Manual, the process remains inconsistent, opaque, and insufficiently stakeholder-involved. Over the past few years, LCD coverage has consolidated.
H.R. 8500 is a bipartisan piece of legislation that would reform the LCD process to ensure that coverage decisions are made by qualified health experts through a transparent, evidence-based process.
Why this matters:
Appropriate stakeholder input must be part of the process.
Decisions need to happen in a timely manner.
Patient interests must remain the central priority.
How you can make a difference:
Send the Action Alert below and ask your member of Congress to cosponsor and pass H.R. 8500.
Highlight this issue on social media and its impact on your work and patients.
For more information, you can read the CAP’s Issue Brief here.
