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The Centers for Medicare & Medicaid Services (CMS). National Coverage Determinations (NCDs) are CMS policies that provide guidance to Medicare Administrative Contractors (MACs) on how to process claims for Medicare services. NCDs are based on scientific evidence and other criteria and are designed to ensure that Medicare beneficiaries receive appropriate, cost-effective health care services.

National coverage determination

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AN national coverage determination (CNCD) it is a U.S national determination on whether medicare will pay for an item or service. It’s a way of usage management and form a medical guidance in treatment.

medicare roof is limited to items and services deemed “reasonable and necessary” for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category).

In the absence of an NCD, an item or service is covered at the discretion of Medicare contractors based on a Local Coverage Determination (LCD). As of 2015, determinations of local scope only become public on appeal and do not set a precedent.

What triggers a CNCD?

DNTs may be ordered by third parties who identify an item or service as a potential benefit (or to avoid potential harm) to Medicare beneficiaries. External parties that may apply for an NCD are Medicare beneficiaries, manufacturers, providers, vendors, medical professional associations, or health plans.

CNCDs can also be generated internally by the Centers for Medicare and Medicaid Services (CMS) in multiple circumstances.

For existing items or services

  • Interested parts raised important concerns about the health benefits of currently covered items or services
  • New evidence or reinterpretation of previously available evidence indicates that current policies may need to be changed
  • Local coverage policies are inconsistent or conflicting, to the detriment of beneficiaries

For new items or services

  • The technology represents a substantial clinical advance and is likely to result in significant health benefits if it is available more quickly to the patients for whom it is indicated.
  • Faster access is likely to have a significant programmatic impact on Medicare policies
  • There is significant uncertainty regarding health benefits, selection of appropriate patients or facilities, and staffing requirements

The NCD decision process

The NCD development process typically takes 6-9 months, depending on the need for external technology assessments or coverage advisory committee reviews. For NCD applications that do not require these assessments/reviews, the entire NCD decision will be made within 6 months of the date the application is received.

Phases during the first 6 months:

  • preliminary discussions
  • benefit category
  • Request for National Coverage
  • team review
  • External Technology Assessment and/or Medicare Coverage Advisory Committee
  • team review
  • Draft Decision and Published Memorandum

Phases in the last 3 months

  • public comments (30 days)
  • Final Decision Memorandum and Implementation Instructions (must be completed within 60 days)

List of DNTs and LCDs

NCD decisions are binding on all Medicare contractors, and LCD policy cannot be more restrictive than NCD, although it can be less restrictive. If an NCD or other coverage provision states that an item is “covered for A, B, and C diagnoses/conditions,” contractors should not use this as a basis for developing an MDC to cover only “A, B, and C diagnoses/conditions “. When a DNT does not exclude coverage for other diagnoses/conditions, contractors must allow for individual consideration unless the LCD supports automatic denial of some or all of these other diagnoses/conditions. When national policy bases coverage on an assessment of needs by the beneficiary’s provider, MDCs should not include prerequisites.

Evaluating LCDs for CNCD consideration

The CMS is required (under the MMA) to assess the LCDs to decide which decisions should be taken nationally. When new LCDs are developed, a 731 Advisory Group reviews LCD topic submissions to determine which topics are forwarded to the CMS Review and Coverage Group (CAG).

To promote consistency across LCDs, CMS requires Medicare contractors to:

  • Consult with other contractors before developing a new policy
  • Adopt or adapt existing LCDs when possible

References

External Links


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