Menu
Home
People
Places
Arts
History
Plants & Animals
Science
Life & Culture
Technology
Reference.org
National coverage determination
open-in-new
<h2 id="what-triggers-an-ncd">What triggers an NCD?</h2> <p>Source:<a class="footnote-ref" id="fnref:5" href="#fn:5"><sup>5</sup></a> </p><p>NCDs can be requested by external parties who identify an item or service as a potential benefit (or to prevent potential harm) to Medicare <a href="/facts/Beneficiary/anFXQG6b">beneficiaries</a>. External parties who may request an NCD are Medicare beneficiaries, manufacturers, providers, suppliers, medical professional associations, or health plans. </p><p>NCDs can also be internally generated by the <a href="/facts/Centers_for_Medicare_and_Medicaid_Services/L3LgbCnx">Centers for Medicare and Medicaid Services (CMS)</a> under multiple circumstances. </p><p>For existing items or services </p> <ul><li><a href="/facts/Stakeholder_theory/X3SIp6om">Stakeholders</a> have raised significant questions about health benefits of currently covered items or services</li> <li>New evidence, or re-interpretation of previously available evidence indicates that current policies may need to be changed</li> <li>Local coverage policies are inconsistent or conflicting, to the detriment of beneficiaries</li></ul> <p>For new items or services </p> <ul><li>The technology represents a substantial clinical advance and is likely to result in significant health benefit if it is available more rapidly to patients for whom it is indicated</li> <li>More rapid access is likely to have a significant programmatic impact on Medicare policies</li> <li>Significant uncertainty exists around health benefits, patient selection, or appropriate facility and staffing requirements</li></ul> <h2 id="the-ncd-decision-process">The NCD decision process</h2> <p>The NCD development process generally takes 6–9 months, depending on the need for external technology assessments or coverage advisory committee reviews. For NCD requests that do not require these assessments/reviews, the entire NCD decision will be made no more than 6 months after the date the request is received.<a class="footnote-ref" id="fnref:6" href="#fn:6"><sup>6</sup></a> Phases during the first 6 months: </p> <ul><li>Preliminary Discussions</li> <li>Benefit Category</li> <li>National Coverage Request</li> <li>Staff Review</li> <li>External Technology Assessment and/or Medicare Coverage Advisory Committee</li> <li>Staff Review</li> <li>Draft Decision and Memorandum Posted</li></ul> <p>Phases during last 3 months </p> <ul><li><a href="/facts/Public_comment/uNPVrgX8">Public Comments</a> (30 days)</li> <li>Final Decision Memorandum and Implementation Instructions (must be completed in 60 days)</li></ul> <h2 id="relationship-of-ncds-and-lcds">Relationship of NCDs and LCDs</h2> <p>NCD decisions are binding on all Medicare contractors, and LCD policy can be no more restrictive than the NCD, although it can be less restrictive.<a class="footnote-ref" id="fnref:7" href="#fn:7"><sup>7</sup></a> If an NCD or other coverage provision states that an item is "covered for diagnoses/conditions A, B and C", contractors should not use that as a basis to develop an LCD to cover only "diagnoses/conditions A, B and C". When an NCD does not exclude coverage for other diagnoses/conditions, contractors should allow individual consideration, unless the LCD supports automatic denial of some or all of those other diagnoses/conditions. When national policy bases coverage on need assessment by the beneficiary's provider, LCDs should not include prerequisites.<a class="footnote-ref" id="fnref:8" href="#fn:8"><sup>8</sup></a> </p> <h2 id="evaluating-lcds-for-ncd-consideration">Evaluating LCDs for NCD consideration</h2> <p>CMS is required (under the MMA) to evaluate LCDs to decide which decisions should be adopted nationally. When new LCDs are developed, a 731 Advisory Group reviews LCD topic submissions to determine which topics are forwarded to the CMS Coverage and Analysis Group (CAG).<a class="footnote-ref" id="fnref:9" href="#fn:9"><sup>9</sup></a> </p><p>To promote consistency across LCDs, CMS requires Medicare contractors to:<a class="footnote-ref" id="fnref:10" href="#fn:10"><sup>10</sup></a> </p> <ul><li>Consult with other contractors prior to developing a new policy</li> <li>Adopt or adapt existing LCDs when possible</li></ul> <h2 id="external-links">External links</h2> <ul><li><a href="https://www.cms.hhs.gov/mcd/overview.asp">Medicare Coverage Database - Overview</a> at cms.hhs.gov</li> <li><a href="http://medicarelaw.info/wiki/NCD">NCD</a> at medicarelaw.info</li> <li><a href="http://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx">CMS National Coverage Determination Database</a> at cms.gov</li></ul> <h2 id="references">References</h2> <ol> <li id="fn:1"><p>"Medicare Coverage Determination Process | Guidance Portal". www.hhs.gov. Retrieved 2023-05-17. <a href="https://www.hhs.gov/guidance/document/medicare-coverage-determination-process-0" target="_blank">https://www.hhs.gov/guidance/document/medicare-coverage-determination-process-0</a> <a href="#fnref:1" class="footnote-back-ref">↩</a></p></li> <li id="fn:2"><p>"Medicare Program; Revised Process for Making Medicare National Coverage Determinations" (PDF). CMS/HHS. <a href="http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf" target="_blank">http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf</a> <a href="#fnref:2" class="footnote-back-ref">↩</a></p></li> <li id="fn:3"><p>"Medicare Program; Revised Process for Making Medicare National Coverage Determinations" (PDF). CMS/HHS. <a href="http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf" target="_blank">http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf</a> <a href="#fnref:3" class="footnote-back-ref">↩</a></p></li> <li id="fn:4"><p>Dolgin, Janet (2015-01-01). "Unhealthy Determinations: Controlling "Medical Necessity"". Virginia Journal of Social Policy & the Law: 436. <a href="https://scholarlycommons.law.hofstra.edu/faculty_scholarship/1067" target="_blank">https://scholarlycommons.law.hofstra.edu/faculty_scholarship/1067</a> <a href="#fnref:4" class="footnote-back-ref">↩</a></p></li> <li id="fn:5"><p>"Medicare Program; Revised Process for Making Medicare National Coverage Determinations" (PDF). CMS/HHS. <a href="http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf" target="_blank">http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf</a> <a href="#fnref:5" class="footnote-back-ref">↩</a></p></li> <li id="fn:6"><p>"Medicare Program; Revised Process for Making Medicare National Coverage Determinations" (PDF). CMS/HHS. <a href="http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf" target="_blank">http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf</a> <a href="#fnref:6" class="footnote-back-ref">↩</a></p></li> <li id="fn:7"><p>"Medicare Program; Revised Process for Making Medicare National Coverage Determinations" (PDF). CMS/HHS. <a href="http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf" target="_blank">http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf</a> <a href="#fnref:7" class="footnote-back-ref">↩</a></p></li> <li id="fn:8"><p>"Medicare Program; Revised Process for Making Medicare National Coverage Determinations" (PDF). CMS/HHS. <a href="http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf" target="_blank">http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf</a> <a href="#fnref:8" class="footnote-back-ref">↩</a></p></li> <li id="fn:9"><p>"Medicare Program; Revised Process for Making Medicare National Coverage Determinations" (PDF). CMS/HHS. <a href="http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf" target="_blank">http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf</a> <a href="#fnref:9" class="footnote-back-ref">↩</a></p></li> <li id="fn:10"><p>"Medicare Program; Revised Process for Making Medicare National Coverage Determinations" (PDF). CMS/HHS. <a href="http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf" target="_blank">http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf</a> <a href="#fnref:10" class="footnote-back-ref">↩</a></p></li> </ol>