Coverage Determinations

Medicare coverage policies

  • Part A of Title XVIII of the Social Security Act is the rimary authority for all coverage provisions & subsequent policies. Section 1862 (a)(1)(A)
  • Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury within the scope of a Medicare benefit category

Contractors' tools for applying policies

  • Regulations
  • Coverage provisions in interpretive manuals
  • National coverage determinations
  • Local coverage determinations
Search the Medicare Coverage Database for 
national and local coverage determinations 

National Coverage Determinations (NCDs)

NCDs set forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis.

  • Developed through an evidence-based process, with opportunities for public participation. 
  • CMS research may be supplemented by an outside technology assessment and/or consultation with the Medicare Coverage Advisory Committee (MCAC).
  • Developed to describe circumstances for specific medical service procedure or devices.
  • Once published, and if made under Section 1862(a)(1), NCDs are binding on Administrative Law Judges in the appeal process.

Local Coverage Determinations (LCDs)

If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, it is at the disrection of the Medicare contractor to create a local coverage determination (LCD). LCDs are decisions by fiscal intermediaries or carriers about whether to cover a particular service on an intermediary-wide or carrier-wide basis.

Section 522 of BIPA established the term, defined as a decision by a Medicare contractor (Part A or B, as applicable) whether to cover a particular service on an intermediary or carrier wide basis in accordance with section 1862 (a)(1)(A). LCDs:

  • may provide that a service is not reasonable & necessary for certain diagnoses and/or for certain diagnoses codes.
  • do not include a determination of which procedure code, if any, is assigned to a service or a determination with respect to the amount of payment to be made for the service.
  • specify under what clinical circumstances a service is considered to be reasonable & necessary.
  • are an administrative & educational tool to assist providers in submitting correct claims for payment.
  • are developed by considering medical literature, advice of local medical societies & medical consultants, and comments from the provider community.
  • are not binding on Qualified Independent Contractors (QICs) or Administrative Law Judges (ALJs) during claims adjudication-appeals process, so any claim can be paid without challenging the applicable LCD. 
View local coverage determinations:
By Contractor  | By StateBy CPT/HCPCS/ICD Code


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