Some Medicare beneficiaries may feel overwhelmed by the complex rules and regulations related to Medicare. This is especially true when a person who has Medicare receives a notice that their procedure or service needs prior authorization or if the Medicare beneficiary receives a notice of denial of their service, or on an other medical need.
National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) helps Medicare providers and Medicare beneficiaries understand some rules and decisions made by Medicare.
What are Medicare Coverage Document Type Descriptions and how do they relate to NCDs and LCDs?
Medicare provides primary care physicians, specialist doctors, and specialists such as radiologists and laboratory specialists with a description of the decisions made about coverage for a specific service or item. The Centers for Medicare and Medicaid Services (CMS) provides the Medicare Coverage Document Type Descriptions. The document explains the types of coverage decisions, how each of them makes decisions about the services, procedures and items that Medicare covers and what they do not cover for Medicare beneficiaries.
The Medicare Coverage Document Type Descriptions describes terms that relate to both Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
The Medicare Administrative Contractor is required to follow all of the National Coverage Determinations (NCDs) made by Medicare.
What are National Coverage Determinations (NCDs)?
National Coverage Determinations are the determinations that specify the coverage of specific services or items by Medicare. The American College of Radiology explains that the Secretary of the U.S. Department of Health and Human Services (HHS) makes decisions about whether a particular item or service is covered nationally by Medicare, “which essentially grants, limits or excludes national coverage to all Medicare beneficiaries.”
National Coverage Determinations apply to all states. They approve, limit or exclude coverage of an item or service to all Medicare beneficiaries across the U.S. The NCDs set forth the extent of coverage by Medicare for various types of procedures, services or technologies on a nationwide basis.
Surprisingly 90% of Medicare policies are established at the local level, called the Local Coverage Determinations (LCDs) and not the national level.
What are Local Coverage Determinations (LCDs)?
Local Coverage Determinations (LCDs) are decisions made by the Medicare Administrative Contractors (MAC) about whether a particular service or item meets the requirement for being reasonable and necessary. No National Coverage Determinations (NCDs) exist for services or items defined by the Local Coverage Determinations.
The CMS document explains that a Local Coverage Determination (LCD) is a decision made by a Medicare Administrative Contractor (MAC) about whether a specific service or item is deemed to be reasonable and necessary, “and therefore covered by Medicare within the specific jurisdiction” that the MAC oversees.
Local Coverage Determinations are policies that are specific to a local level. This is why there could be scenarios where you received a denial of your procedure, item or service, but your relative or friend who resides in a different state received approval for the same or a similar item, service or procedure.
The MACs create Local Coverage Determinations (LCDs) when there is no National Coverage Determination (NCD). One example is when there is a new service or item. The CMS document also explains that an LCD may be made “when there is a need to further define an NCD for the specific jurisdiction.”
The Medicare Administrative Contactor is required to follow the rules for the National Coverage Determinations.
How Do I Learn More about Policy or Document Information or Denials?
The Medicare Coverage Database (MCD) provides the opportunity for Medicare beneficiaries to learn about and find coverage documents.
The MCD database provides an easy explanation to help you find the documents that you need and to help you navigate the site. It also helps Medicare beneficiaries to better understand the denial of services or items.
- Medicare Coverage Document Type Descriptions, CMS.gov.
- National and Local Coverage Determinations – American College of Radiology
- Guide to the MCD Search for Beneficiaries, CMS.gov.