CodeMap®-National Coverage Determinations (2024)

FAQs

What is national determination of coverage? ›

National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation. In some cases, CMS' own research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC).

NCDs are binding on all Medicare Administrative Contractors (MACs), Quality Improvement Organizations (QIOs), Administrative Law Judges (ALJs) and the Medicare Appeals Council. Local Coverage Determinations (LCDs) are decisions by a local MAC, and are applicable only within the issuing MAC's jurisdiction(s).

MACs develop an LCD when there is no national coverage determination (NCD) or when there is a need to further define an NCD for the specific jurisdiction. LCDs outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements.

An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis.

Some examples of a coverage determination are: If you ask us to make an exception,* including: Asking us to cover a Part D drug that is not on the plan's formulary (our list of covered drugs) Asking us to waive a restriction on the plan's coverage for a drug (such as limits on the amount of the drug you can get)

Relationship of NCDs and LCDs:

NCD decisions are binding on all Medicare contractors, and LCD policy can be no more restrictive than the NCD, although it can be less restrictive.

Turn off the computer. Connect the AC power adapter. Press Fn, left Ctrl, and the power button at the same time. If the LCD panel displays at least five solid colors in sequence across the entire screen, it indicates that the LCD is functioning normally.

NCD s are developed by CMS to describe the circ*mstances for Medicare coverage nationwide for a specific medical service procedure or device.

In addition to creating the term “Local Coverage Determination” (LCD), section 1869(f) of the Social Security Act creates an appeals process for an “aggrieved party” to challenge LCDs/LCD provisions that are in effect at the time of the challenge.

If an NCD or LCD does not exist, it does not simply mean that Medicare will not pay for the service. CMS develops NCDs to codify Medicare coverage of services that are “reasonable and necessary.” NCDs are created using an evidence-based process, with opportunities for public comment and participation.

What does LCD mean with Medicare? ›

What's a "Local Coverage Determination" (LCD)? LCDs are decisions made by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service in a MAC's jurisdiction (region) in accordance with section 1862(a)(1)(A) of the Social Security Act.

MA organizations must follow all Traditional Medicare NCDs, LCDs applicable to the MA plan's service area, and general coverage and benefit conditions included in Traditional Medicare per 42 CFR § 422.101.

The LCD or article contains outdated technology, or the service or item is considered standard of care. It is determined that the LCD or article is no longer being used as an educational tool. Utilization of the service or item addressed by the LCD or article is very low.

What's a "Local Coverage Determination" (LCD)? LCDs are decisions made by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service in a MAC's jurisdiction (region) in accordance with section 1862(a)(1)(A) of the Social Security Act.

National Coverage means, with respect to any television network, the percentage of national television households that receive such network's broadcast as listed in the Nielsen Television Index or such successor measure of coverage equivalent thereto generally adopted by the television industry.

NCD s are developed by CMS to describe the circ*mstances for Medicare coverage nationwide for a specific medical service procedure or device. NCD s generally outline the conditions for which a service is considered to be covered (or not covered) and usually issued as a program instruction.

National Coverage Determinations are coverage guidelines that are mandated at the Federal level. Local Coverage Determinations are mandated by the MAC. They both determine whether to cover a particular medical service in accordance with whether it is reasonable and medically necessary.