Medicare Coverage Activities: How ACR Helps Your Practice

National Coverage Determinations (NCDs) are binding on all Medicare contractors, quality improvement organizations, health maintenance organizations, competitive medical plans and healthcare prepayment plans. The Secretary of the Department of Health and Human Services determines whether a particular item or service is covered nationally by Medicare, which essentially grants, limits or excludes national coverage to all Medicare beneficiaries. These determinations are binding on all Medicare contractors and outline the conditions for which a service is covered or not covered. These determinations are based on evidence, including medical and scientific information, FDA data, and clinical trial information.

Anyone can request an NCD from CMS. However, "aggrieved" beneficiaries, defined as "individuals entitled to benefits under Part A, or enrolled under Part B, or both, who are in need of the items or services that are the subject of the coverage determination", are given priority.

CMS has outlined a specific process, which takes nine months or more from the date the complete request is received by CMS to the date that coverage changes are implemented. 

Learn more through the NCD Dashboard

The Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) advises CMS on whether specific medical items and services are reasonable and necessary under Medicare law related to certain NCD submissions. MEDCAC performs a detailed analysis and provides comments regarding specific clinical and scientific issues in an open and public forum but CMS makes the final decision on coverage issues.

See the current roster

An LCD, as defined in §1869(f)(2)(B) of the Social Security Act (SSA), is a determination by a Medicare Administrative Contractor (MAC) regarding whether or not a particular item or service is covered on a contractor–wide basis in accordance with section 1862(a)(1)(A) of the Act. Medicare Administrative Contractors (MACs) establish LCDs.

90% of Medicare policies are established at the local level, providing contractors with tremendous authority over payment policy in a given state. Representatives of the ACR® Radiology, Radiation Oncology and Nuclear Medicine Contractor Advisory Committee (CAC) Network advocate on behalf of radiology for fair reimbursement policies at the local Medicare level.

By reviewing and commenting on Local Coverage Decisions (LCDs) and proposed policy changes, the CAC networks help ensure that members are appropriately reimbursed for medically reasonable and necessary services provided to Medicare patients.

When a Medicare contractor develops a new LCD or significantly revises an existing one, a 45-day public comment period is required. During this time, Contractor Medical Directors (CMDs) solicit input from members of the CAC. Comments can be submitted to the CMD or electronically through your Medicare contractor's website. After the CMDs have considered all comments received, there is a 45-day notice period prior to implementation of the final LCD. Providers and billing staff should track LCD changes using the Medicare Coverage Database. The Centers for Medicare and Medicaid Services (CMS) has revised rules for the development and administration of Medicare Local coverage determinations (LCDs).