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CMS revamps the Medicare program integrity manual to accelerate innovation, access to technology

Reforms to local coverage determination process will increase transparency and patient engagement to ensure beneficiaries can get the latest benefits

Susan Morse, Managing Editor


As part of a broader effort to modernize the Medicare program through IT and innovation, the Centers for Medicare and Medicaid Services today announced changes to the way contractors decide which technologies are covered.

CMS has revised its Medicare program integrity manual in updates that follow 21st Century Cures Act requirements for more transparency in the local coverage determination, or LCD, process. 

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In this first revision since August 2015, the manual has been revamped as a roadmap for the LCD process. 

It lays out CMS's expectations for Medicare Administrative Contractors. MACs determine which healthcare items and services meet requirements for Medicare coverage, taking into account local coverage determinations. 

LCDs are issued when national determinations do not exist, or when the contractors need to further define a national determination.  


The changes will clarify and simplify the process, helping to ensure that companies can get therapies and devices to patients more efficiently, CMS said.

The manuel now requires a consistent, standardized summary of the clinical evidence supporting LCD decisions.

It includes a beneficiary representative and other healthcare professionals such as nurses and social workers, in addition to physicians on contactor advisory committees that inform LCDs. 

It ensures that contractor advisory committee meetings are open to the public.

The new process takes further steps to be responsive to patient needs by allowing patients to request a new local coverage determination, and by holding virtual meetings by webinar instead of in-person to allow for broader participation.

CMS is requesting feedback at and will consider additional revisions based on the feedback.


"The redesigned local coverage determination process will pave the way to expanded access to new medical technologies," said CMS Administrator Seema Verma. "Coverage decisions will be made more transparently with an explanation of the clinical evidence that supports them, and with input from beneficiaries who are affected."

Twitter: @SusanJMorse
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