LCD Flashcards
LCD
Local coverage determination is a decision by Medicare administrative contractor (mac) on whether a particular service or product is reasonable and necessary, and therefore covered by Medicare within the specific jurisdiction that mac oversees
ASP
Average sales price is the weighted average price submitted by manufacturers for part B- covered drugs, biologicals, and related items.
- CMS publishes the National payment rate (ASP+6%) quarterly
- this applies to Q code products
Why new LCDs were published
Worsening Medicare spending crisis underscored the need for overhaul
2020 - half a billion
2022 - 1.5 billion
2023 - 4 billion
Over $3,500 per sqr cm for some ASP
- rebate over a billion per month
- multiple new skin grafts / no clinical evidence
Mimedx part in the new lcd
- partnered with clinical stakeholders to advise CMS and the MACS on coverage proposals and revisions
- patient care / access focused solutions
- guidelines based on evidence
- reimbursement for clinically proven and published treatments
Different than LCD in 2023
-Only 3 macs released future effective lcds
- all 7 MACs agreed in unison with CMS
- there were public comments that were reviewed and addressed
- 2024 was revised based on commentary
Summary of LCD changes
- takes effect on 2/12/2025
- only address skin sub for DFU / VLU
- other wounds is for wound care reasonable and necessary
- limit to 8 applications over a 12-16 week period
- 204 skin subs will no longer be covered
- Epifix for dfu and vlu / Epicord dfu
- dfu 17 covered products
- vlu 5 covered products
Why Mimedx made the list
- sharing industry & best practice data
- AHRQ information and Medicare data education
- cooperative and responsive to CMS and MAC in providing information and data , FDA, clinical , etc.
Link to broad commercial coverage which requires elevated data ( 8 level one RCt’s)
