National Coverage Determinations
A National Coverage Determination (NCD) establishes Medicare coverage policy nationally for a specified item or service. Depending on the NCD, coverage may depend on clinical indications, eligibility requirements, diagnostic findings or other conditions.
Local Coverage Determinations
A Local Coverage Determination (LCD) is issued by a Medicare Administrative Contractor (MAC) for its jurisdiction and may address medical necessity, covered indications and documentation requirements for particular services.
Illustrative example
Specialized diagnostic testing
For a requested Medicare diagnostic service, the physician reviewer identifies the applicable coverage framework, checks whether an NCD or relevant local policy applies, and determines whether the submitted record documents the required clinical circumstances.
| NCD | LCD |
|---|---|
| National Medicare coverage policy | Local Medicare coverage policy within the applicable MAC jurisdiction |
| Issued at the CMS national level | Issued by a Medicare Administrative Contractor |
| Evaluated when applicable to the service | Jurisdiction and current effective policy matter |
Current-source principle: coverage policies can change. Reviewers should verify the current applicable CMS/MAC policy at the time of determination.