Reimbursement
LCD and NCD
In one line
Local and National Coverage Determinations from Medicare.
Definition
A National Coverage Determination (NCD) is a Medicare-wide policy on whether and under what conditions an item or service is covered. A Local Coverage Determination (LCD) is issued by a Medicare Administrative Contractor (MAC) for its jurisdiction.
NCDs bind all Medicare contractors, while LCDs apply only within a MAC's region, so coverage can differ between states until an NCD exists. Medicare Advantage plans must follow NCDs and LCDs but may add utilization management. Manufacturers can request a new NCD or LCD, or a reconsideration, by submitting supporting evidence.
Why it matters
Coverage typically begins as LCD policy via one or more MACs; pivotal NCDs (e.g., TAVR, TCAR, TMVR) define the national clinical-evidence and facility/operator standards.
Common pitfalls
- •Misinterpreting an LCD as a national policy can lead to denied claims in other jurisdictions.
- •Failing to consider both NCDs and relevant LCDs when determining coverage for a medical device or service can result in incomplete reimbursement strategies.
- •Assuming that an absence of an NCD means automatic coverage can lead to significant financial losses if an LCD also denies coverage.
- •Not understanding the specific evidence requirements outlined in an NCD or LCD can lead to insufficient clinical trial design or data collection activities.
Sources