National and local coverage determinations are core Medicare coverage authorities. Physician review starts by identifying which policy governs the requested item or service—and whether the submitted record documents the required clinical circumstances.
CMS develops National Coverage Determinations through an evidence-based process. When no controlling national policy resolves the question, Medicare Administrative Contractors may develop Local Coverage Determinations for their jurisdictions, and an LCD may also supplement an NCD so long as it does not conflict with national policy.
When national policy exists, the reviewer applies it first. Local policy may address issues left to contractor discretion or further define requirements within the limits of national Medicare policy.
Billing and Coding Articles and other MAC articles may provide coding or implementation guidance. Reviewers should confirm whether an article directly supports a specific LCD and verify the current effective document in the Medicare Coverage Database.
The physician reviewer does not stop after locating a policy. The review must connect the policy requirements to the patient's documented diagnosis, findings, prior treatment, requested service, and other material clinical facts.
Define the exact item, procedure, diagnostic study, therapy, or technology being reviewed.
Determine whether a current NCD applies and, when appropriate, whether a relevant LCD or associated article governs the jurisdiction.
Assess whether the documentation establishes the required indications, diagnostic findings, prior therapy, eligibility, or other coverage conditions.
Integrate the controlling Medicare coverage requirements with the submitted clinical record and clearly explain the reasoning.
For a requested Medicare diagnostic service, the physician reviewer first determines whether CMS has established national coverage. If the national policy does not fully resolve the question, the reviewer identifies the applicable MAC jurisdiction and searches for relevant local coverage requirements.
The determination then turns on whether the submitted medical record documents the specific indications, findings, prerequisite testing, or other conditions required by the applicable coverage policy.
Reviewers should verify the current CMS or MAC policy, effective dates, jurisdiction, associated articles, and applicable revisions rather than relying on a static historical list.
Discuss NCD/LCD applicability, jurisdiction, documentation requirements, medical necessity, appeals, or complex Medicare review needs.
