Question

If an NCD does not exist for a particular/procedure performed on a Medicare patient, who determines coverage?

Answer 1

If an NCD does not exist for a particular procedure performed on a Medicare patient, the coverage is determined by Local Coverage Determination (LCD) or a Medicare Administrative Contractor (MAC).

Step-by-step explanation:

If an NCD (National Coverage Determination) does not exist for a particular procedure performed on a Medicare patient, the coverage is determined by Local Coverage Determination (LCD) or a Medicare Administrative Contractor (MAC). LCDs define the coverage policies for specific medical procedures or services in a particular geographic area. MACs are responsible for processing and determining Medicare claims for their assigned regions.

For example, if a Medicare patient needs a certain procedure that doesn't have a specific NCD, the MAC or LCD in their region will review the medical necessity and determine if the procedure will be covered by Medicare.