The Centers for Medicare & Medicaid Services (CMS) uses coverage determinations to decide how Medicare should cover treatments, services, and items. These rules usually apply nationwide.

The CMS creates national coverage determinations (NCD) using evidence-based research that involves members of the public.

When deciding how to base coverage, Medicare considers whether items and services are reasonable and medically necessary to diagnose or treat medical conditions or injuries.

While the CMS designs and publishes NCD policies that usually apply to all states, the CMS creates local coverage determinations (LCD) if NCD policies are unavailable.

The CMS uses Medicare administrative contractors (MAC) to develop LCDs.

The MACs decide what’s reasonable and medically necessary for a specific health condition or injury in line with Medicare coverage requirements, and they create an LCD to outline how to process claims.

Sometimes, the CMS uses the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) to provide independent and unbiased clinical guidance on coverage decisions.

When making their report to the CMS, the MEDCAC studies and considers:

  • various medical publications
  • relevant technology
  • public testimony

It also considers information on the specific benefits, limitations, and suitability of the items, services, or treatments assessed for Medicare coverage.

The MEDCAC contains 100 experts in:

  • clinical and administrative medicine
  • biological and physical sciences
  • public health administration
  • patient advocacy
  • healthcare data and information management and research
  • healthcare economics
  • medical ethics

There’s a maximum of 15 panel members for each meeting who have specific knowledge of the coverage topic.

Based on its findings, the MEDCAC makes coverage recommendations to the CMS.

Sometimes, the CMS considers new coverage determination requests from Medicare beneficiaries. You can make a formal request in writing if you do the following:

  • Avoid marking it as a draft document.
  • Label it as “A Formal Request for a National Coverage Determination.”
  • Identify the Medicare-approved benefit category under which you believe the item, service, or treatment deserves coverage, and provide enough information for the CMS to make a benefit category decision.
  • Include enough supporting evidence, such as medical reports.
  • Give information that’s relevant, useful, or of medical benefit to all Medicare beneficiaries.
  • Explain the purpose, method, and design of using the item, service, or treatment.

You can submit an electronic NCD request to NCDRequest@cms.hhs.gov, or send it through the mail to:

The Centers for Medicare & Medicaid Services (CMS)
Director, Coverage and Analysis Group
7500 Security Boulevard
Baltimore, MD 21244

Medicare uses NCDs to establish coverage rules for specific medical items, services, and treatments.

If an NCD doesn’t exist, the CMS may arrange for an LCD through an MAC.

You can formally request an NCD if you meet the CMS’s requirement to provide enough detailed information to serve all Medicare beneficiaries.