A National Coverage Determination (NCD) by the United States Government is a policy decision regarding whether Medicare will provide reimbursement for a specific medical item or service.
Medicare reimbursement is confined to items and services deemed “suitable and necessary” for the diagnosis or medical management of an ailment or injury (and must fall under a Medicare benefit category).
In situations where an NCD does not exist, the coverage status for an item or service is left to the judgment of the Medicare contractors based on a Local Coverage Determination (LCD).
As of the year 2015, LCDs are disclosed only during an appeals process and do not establish legal precedents.
Requests for NCDs may be made by external entities, highlighting an item or service for recognition as a potential benefit (or to avert prospective harm) for those under Medicare. Possible requestors of an NCD include individuals covered by Medicare, product manufacturers, health service providers, equipment suppliers, medical professional groups, or healthcare plans.
Furthermore, NCDs can originate from within the Centers for Medicare and Medicaid Services (CMS) for various reasons.
The Procedure for Medicare Coverage Determination
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 brought modifications to several sections of the NCD establishment process, taking effect as of January 1, 2004.
