Are Medicare’s Local and National Coverage Determinations the Final Word?

By Denise Wilson | October 28, 2019

Local coverage determinations (LCDs) and national coverage determinations (NCDs) are coverage and payment guideline documents published by The Centers for Medicare and Medicaid Services (CMS) or their administrative contractors. Specifically, LCDs are published by Medicare Administrative Contractors (MACs) and generally apply to beneficiaries and medical service providers and suppliers who reside in the geographic regions covered by the MAC. CMS publishes NCDs which apply to all Medicare beneficiaries.

LCD and NCD coverage and payment policies typically apply to specific procedures and services. Many policies apply to outpatient procedures or services, but some also apply to inpatient procedures. Medicare usually develops LCDs and NCDs for procedures or services that are high cost, high volume, or prone to documentation or billing errors.

When a denial cites an LCD or NCD as the basis for denying care, the appeal writer must review the LCD or NCD for guidance on required medical record documentation and billing instructions. The writer must compare the requirements outlined in the LCD or NCD to documentation in the medical record and the submitted claim. If there’s a discrepancy between the documentation and the requirements outlined in the guidance, the appeal writer must determine if there is a reasonable explanation of why the difference exists.

If there is a reasonable explanation of why a discrepancy exists, then there is reason to appeal. For example, the patient may not have been able to tolerate certain conservative treatment measures prior to surgical intervention. Perhaps the patient failed treatment with pain medication because of an adverse reaction.

There are other situations where an appeal may be successful even when the documentation doesn’t fully support the requirements in the guidance. Each MAC publishes its own set of LCDs. Compare similar LCDs from various MACs, and you may find some differences in the required documentation. If one MAC is more restrictive than the other MACs, the appeal writer can argue that the stricter requirements do not represent the standard of care.

Reviewing the articles referenced by the LCD or NCD that were used by the MAC or CMS to develop the guidance can also provide arguments for appeal. Are the articles current and relevant, or do they represent outdated standards of practice?

Finally, Administrative Law Judges who hear Medicare appeals at Level 3 of the appeals process are not bound by LCDs or CMS program guidance. Therefore, if the medical record documentation does not support LCD guidance in total, there still may be an opportunity for a successful appeal and argument. CFR-2010-title42-vol2-sec405-1062.