What are LCDs and NCDs?
Coverage determinations are Medicare's written rules for when a service is reasonable and necessary. NCDs apply nationwide; LCDs are set by each Medicare Administrative Contractor for its region.
Coverage criteria, illustrative
- Service
- Lumbar spine MRI
| Criterion | What the record needs |
|---|---|
| Low back pain with radiculopathy | Exam findings and the diagnosis |
| Six weeks of conservative care, or red flags | Therapy notes, or the red-flag findings |
| Results will change treatment | The plan: surgery consult, injection or similar |
- Medicare policies come with billing and coding articles that list the diagnosis codes that support coverage.
Medicare covers services that are reasonable and necessary. Coverage determinations spell out what that means for specific services.
- National Coverage Determinations (NCDs) are set by CMS and apply everywhere.
- Local Coverage Determinations (LCDs) are set by each Medicare Administrative Contractor and apply in its jurisdiction, where no NCD exists or to add detail.
Commercial payers publish their own medical policies, which work the same way.
Why they matter for billing
A service that doesn’t meet the policy is denied as not medically necessary, CO-50, or for a non-covered diagnosis. The policy is also the best appeal tool: it lists the exact criteria, so the appeal can answer each one with the record.
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