What is a Medicare Coverage Determination?

Medicare Benefits Solutions
Jul 6, 2021

What is a Medicare Coverage Determination? For all Medicare recipients, it is important to get coverage for medical services and supplies that are necessary for their health care. In order to get these vital Medicare benefits, Medicare must establish which services and items it pays for. To do this, it uses a nationwide management system known as coverage determination. 

National Coverage Determinations (NCDs) are individual decisions made on particular treatments and supplies that become Medicare benefits. To meet Medicare’s coverage requirements, the treatment or medical item must be reasonable and necessary for the diagnosis and treatment of illness or injury. To determine this, the United States federal government continuously reviews new treatments and medical items so Medicare can update coverage allowances for beneficiaries.

When new coverage decisions are authorized, modifications are made to Medicare’s coverage and all Medicare-affiliated providers are required to add them to their benefit plans.

Who can request a National Coverage Determination?

Medicare beneficiaries, manufacturers, health care providers, suppliers, medical professional associations, and health insurance providers can request a National Coverage Determination. This is possible when the requesting party can establish that the medical service or item in question is something that can benefit Medicare recipients or prevent harm to them. 

Additionally, the Centers for Medicare & Medicaid Services (CMS) can initiate NCDs internally in certain situations.

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How can Medicare recipients request an NCD?

If you want to request an NCD from CMS, you have to follow the required procedures. The entire process generally takes between six and nine months from beginning to end. In order to have your request considered as complete and formal by CMS, you must meet the following conditions:

• Your request must be in writing and marked clearly as “A Formal Request for National Coverage Determination”. 

• Your request must identify the benefit category (as CMS statutorily defines it) that the service or item applies to. You must also include details so CMS can make the benefit category determination.

• Your request must include sufficient documentation to support the evidence for an NCD.

• All the information included must support the relevance, usefulness, and/or the medical benefits of the medical service or item for Medicare beneficiaries.

• All information must explain, in detail, the purpose, design, and how to use the item or service that is the subject of the NCD.

You can submit your request for an NCD electronically to [email protected], or by mail to the Centers for Medicare and Medicaid Services; Director, Coverage and Analysis Group; 7500 Security Boulevard, Baltimore, MD. 21244.

What’s the difference between National and Local Coverage Determination?

If an NCD doesn’t exist, coverage for a medical service or item is determined by a Medicare Administrative Contractor (MAC) through a Local Coverage Determination. A MAC is a private health care insurance provider that is Medicare-affiliated and who sells Medicare Advantage (Part C) and/or Medicare stand-alone prescription drug (Part D) plans to beneficiaries. 

As a Medicare beneficiary you can challenge an LCD if the following apply:

• You are eligible for Medicare benefits and are enrolled in either Medicare Part A, Part B, or both. 

• You need the medical services or items that have been determined to not be covered by the LCD in question. 
You can file your LCD challenge under the following circumstances:

• If you haven’t received the service or item: You must file your request within six months of the date that your physician has stated in writing that you need the item or service. 

• If you have received the service or item: You must file the request within 120 days of the initial date you received notice of denial from the MAC that filed the LCD. 

If you challenge an LCD, you should include the following:

• Your name, mailing address, state of residence, and phone number.
• Your health insurance claim number, if applicable.
• Your email address, if applicable.
• The title of the LDC you’re challenging.
• The specific provision of the LCD that affects you.
• The name of the MAC that initiated the LCD.
• A statement explaining what service or item you need, why the LCD is incorrect, and why you’re challenging it. 
• A written statement from the health care provider who is treating you. This statement should explain why you need the service or item, and it should include clinical or scientific information supporting reasons why the LCD should be revised or not used. 

You can send your LCD challenge to the Department of Health and Human Services; Departmental Appeals Board, MS 6132; Civil Remedies Division at 330 Independence Ave., S.W. Cohen Building Room G-644, Washington D.C. 20201.

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