LCD and NCD
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.What this means in practice
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.Examples
- A MedTech manufacturer developing a new diagnostic imaging device must review existing NCDs and relevant LCDs to understand the evidence required for Medicare coverage and reimbursement.
- A quality assurance team ensures that product labeling and marketing materials accurately reflect the limitations and conditions of coverage specified in applicable NCDs and LCDs.
- During clinical trial design, a regulatory professional considers the data requirements outlined in potential NCDs or LCDs to ensure the study generates sufficient evidence for future reimbursement.
- •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.
Frequently asked questions
Related terms
Grouped by themeEditor's picks
· Hand-selected related conceptsReimbursement & Market Access
· From this learning pathPrivate contractors that process Medicare Part A/B and DME claims and issue Local Coverage Determinations within their jurisdictions.
Medicare coverage policies issued nationally (NCD) or by individual MAC contractors (LCD).
Financial model that estimates the total cost consequences of adopting a new technology to a payer's budget over a defined horizon.
AMA-maintained codes that describe medical procedures and services.
Where this term appears across MedTech Terms.
- Reimbursement & Market AccessLesson 6 of 14
Sources
3 sourcesSources support the definition or relevant regulatory context, not necessarily every claim on this page. Each is graded against our source-tier hierarchy so you can see what rests on binding law versus commentary.
Official citation replacements checked: . Medicare documents support Medicare coding, coverage or payment context, not every payer policy or CPT editorial procedure. Citation replacement does not change the full term review date.
- 142 CFR § 405.1060 : Applicability of NCDsTier 1 VerifiedeCFRecfr.gov
- 242 CFR § 405.1062 : Applicability of LCDsTier 1 VerifiedeCFRecfr.gov
- 3Medicare coverage determination process: national and local decisionsTier 2 UncheckedCMScms.gov
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