Chapter 5 - Denials Medical Policies

Question 1

National Coverage Determinations (NCD) and Local Coverage Determinations (LCD)

Answer 1

The NCD Manual indicates whether specific medical services, items, treatment procedures, or technologies can be paid for by Medicare.

Question 2

Medicare contractors are required to follow NCDs unless an NCD does not specifically exclude or limit an indication or circumstance, or if the item or service is not mentioned at all in either the NCD or a Medicare manual

Answer 2

An LCD is mandated at the MAC level.

Question 3

The guidelines given are only applicable to that specific MAC’s jurisdiction.

Answer 3

Medicare contractors develop the LCDs when there is no NCD or when there is a need to further define an NCD.

Question 4

COMMERCIAL PAYER MEDICAL POLICIES

Answer 4

Commercial carriers will develop their own medical policies. These are often available on the payer’s website but only accessible with a provider login. Commercial medical policies will include much of the information available on Medicare NCDs and are typically updated through monthly newsletters from the payer.