What is a retired coverage policy?

What happens when a Local Coverage Determination (‘LCD”) is retired?

When a policy is retired, it means that the specific diagnosis and coverage requirements of the policy are no longer in effect. Therefore claims will not be denied based on the policy provisions after the retirement date.

For example, a policy might have restricted knee replacement to a specific set of diagnoses and/or prior episodes of rehab interventions. The payer reviews the policy and decides to retire it because there is little evidence of abuse, the policy is too restrictive, the indications for use are expanding beyond what was originally considered, or other similar situations.

Once a policy is retired, claims will be presumptively covered. In other words, claims will not be denied based just on diagnosis code or other restrictions that used to exist in the medical policy.

The payer still, as with all claims, has the right to review medical records to verify medical necessity and documentation of appropriate clinical indications. And sometimes, but not always, they will undertake a new clinical review and introduce a brand new policy at a later time to replace a retired policy.