Medicare LCDs vs. NCDs

Have you ever wondered why Medicare covers certain items or services but not others? It all typically comes down to medical necessity – whether the Centers for Medicare & Medicaid Services (CMS) believes those items or services are considered reasonable and necessary for treating your illness or injury.

Sometimes Medicare creates a coverage policy known as a National Coverage Determination (NCD) that applies nationwide. Other times, it lets your Medicare Administrative Contractor (MAC) – the private healthcare insurer that actually processes your Medicare claims – decide what can be covered.

When your MAC makes a coverage decision, it publishes a Local Coverage Determination (LCD) that only applies to your MAC’s specific region.

This guide details what you need to know about Medicare NCDs vs. LCDs in medical billing and how these important policies can help you better understand your Medicare coverage.

What Is a Medicare NCD?

An NCD defines coverage for a particular item (e.g., a brace or hearing aid) or service (e.g., therapy or screenings) nationwide. For example, a Medicare national coverage decision might specify coverage restrictions based on certain clinical conditions, prerequisite treatments and other factors.

Before creating an NCD, Medicare conducts a comprehensive, evidence-based review process with the opportunity for public participation.

There are currently 348 NCDs in place. For example, there are NCDs for blood glucose testing, blood transfusions, bone density studies, heart transplants, lung cancer screenings, mammograms and much more. Once Medicare publishes an NCD, all MACs must follow it.

What Is a Medicare LCD in Medical Billing?

LCD Stands for Local Coverage Determination.

An LCD in medical billing defines Medicare coverage for items and services for which no NCD exists. For example, there might be a local coverage determination for a new service or an item for which Medicare hasn’t yet published an national coverage determination.

A MAC creates an LCD when it determines an item or service shouldn’t be covered under certain circumstances or when it detects over-utilization or misuse of items or services. Before creating an LCD, MACs must obtain local stakeholder input as well as formal input from state-based physician advisory committees. In addition, each MAC has a physician serving as the contractor’s medical director who helps develop and manage the LCD.

There are currently 1,005 final LCDs and 176 proposed LCDs in place. For example, there are final LCDs for canes and crutches, cataract surgery, debridement services, diagnostic colonoscopies, electrocardiograms, hospice care and much more.

Keep in mind that LCDs are specific to your MAC’s jurisdiction and can therefore vary by region. For example, a service might be covered to treat a certain diagnosis in Massachusetts where you live; however, your friend who moved to Florida after retirement might not have that same coverage – even though you both have Medicare.

Is There One Place I Can Go to Find Information About NCDs and LCDs?

Yes. The Medicare Coverage Database includes both LCDs and NCDs that are currently in place. Medicare provides a guide to help beneficiaries navigate the database.

You can also contact your MAC directly or call 1-800-MEDICARE for other questions.

What Should I Keep in Mind When Reading an NCD or LCD?

It’s easy to become overwhelmed when reading an NCD or LCD in medical billing because they usually include a lot of clinical language. The “coverage guidance” is an important one to read, because that will explain any indications, limitations or medical necessity for a given service or item.

You could also explore the online “billing and coding” document under “related local coverage documents” (for each LCD). The billing and coding document explains what specific diagnosis codes your physician must report on the claim for the item or service to be covered.

If you don’t have a covered diagnosis, that could be one reason why Medicare won’t pay for the service in question. Another reason may be that you may not meet criteria for medical necessity. For more information, talk to your physician.

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Can I Challenge an NCD or LCD?

Yes. If you don’t agree with an LCD or NCD, you can challenge it if you have Medicare Part A or B (or both) and you need the item or service not covered by the NCD or LCD.

To file an NCD appeal or complaint, follow these instructions. To file an LCD challenge, follow these instructions.