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National Coverage Determinations The statutory and policy framework within which National Coverage Decisions (NCDs) are made may be found in title XVIII of the Social Security Act (the Act), and in Medicare regulations and rulings. The National Coverage Determinations Manual describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare. All decisions that items, services, etc. are not covered are based on §1862(a)(1) of the Act (the "not reasonable and necessary" exclusion) unless otherwise specifically noted. Where another statutory authority for denial is indicated, that is the sole authority for denial. Where an item, service, etc. is stated to be covered, but such coverage is explicitly limited to specified indications or specified circumstances, all limitations on coverage of the items or services because they do not meet those specified indications or circumstances are based on §1862(a)(1) of the Act. Where coverage of an item or service is provided for specified indications or circumstances but is not explicitly excluded for others, or where the item or service is not mentioned at all in the CMS Manual System the Medicare contractor is to make the coverage decision, in consultation with its medical staff, and with CMS when appropriate, based on the law, regulations, rulings and general program instructions The coverage decisions in the manual will be kept current, based Local Coverage Determinations Local Coverage Determinations (LCDs) are developed to specify under what clinical circumstances a service is reasonable and necessary. They serve as an administrative and educational tool to assist providers in submitting claims correctly for payment.
Page Last Modified: 12/14/2005 1:53:00 PM
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