Final answer:
When there is no NCD for a Medicare service, the Medicare Administrative Contractor (MAC) usually determines coverage. Physicians provide input, but the ultimate decision on coverage is not theirs. CMS oversees the program while CPT guidelines assist in defining services.
Step-by-step explanation:
Who Determines Medicare Coverage if No NCD Exists?
If an National Coverage Determination (NCD) does not exist for a particular service or procedure performed on a Medicare patient, the determination of coverage is usually made by the Medicare Administrative Contractor (MAC). While the physician providing the service may have input on whether the service is necessary, they do not have the final say on coverage. Current Procedural Terminology (CPT) guidelines and the Centers for Medicare & Medicaid Services (CMS) also play roles in defining services and overseeing the Medicare program, but when it comes to individual service coverage decisions without an NCD, the MAC is typically responsible.
Medicare part A pays some hospital charges for eligible individuals, funded by payroll deductions. Medicaid provides health care coverage for poor and disabled Americans, with federal and state governments sharing the costs. The Patient Protection and Affordable Care Act (ACA or Obamacare) introduced additional health care reforms but did not change the fundamental role of the government in Medicare.