Medicare LCD and Local Coverage Determinations

What is a Medicare LCD?

Social Security Act (the Act) Section 1869(f)(2)(B) defines Medicare Local coverage determinations (LCDS). This section provides:

“For purposes of this section, the term ‘local coverage determination’ means a determination by a fiscal intermediary [comment: also known as a Medicare Administrative Contractor, or ‘MAC’] or a carrier under [Medicare] part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1862(a)(1)(A).”

What is a Medicare NCD?

Medicare National Coverage Determinations or Medicare NCDs set national policy in a broad way.  NCDs are supposed to be ‘evidence-based,’ meaning that they are based on objective medical data.  CMS uses “MEDCAC” to do this.  The Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) was established to provide independent guidance and expert advice to CMS on specific clinical topics.

Medicare LCD Modernization

The U.S. Office of the Inspector General (OIG) has pointed out that LCDs have been inconsistent and sometimes conflicting.

As a result, the Centers for Medicare and Medicaid Services (CMS) started an LCD modernization process.  CMS has revised the Medicare Program Integrity Manual (PIM), Chapter 13 – Local Coverage Determinations (Pub 100-08).

Medicare Administrative Contractors (or ‘MACs) have the authority and responsibility to develop LCDs for their jurisdictions.  CMS also intends that LCDs are consistent between all MACs and all jurisdictions and expects that MACs meet and confer regarding these consistencies prior to publication of an LCD.

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The new process is intended to provide greater transparency, consistency and patient engagement, as well as support larger CMS innovation initiatives. The revised PIM guides stakeholders by describing the process, what to expect, and how to provide feedback to MACs. It also clarifies CMS’s expectations for MACs.

For example, the new PIM provides the following component of its process before a Medicare LCD is finalized.

“After the proposed LCD is made public, MACs shall hold open meetings to discuss the review of the evidence and the rationale for the proposed LCD(s) with stakeholders in their jurisdiction. The open meeting should endeavor to accommodate some in-person attendance, subject to limitations based on venue. Interested parties (generally those that would be affected by the LCD, including providers, physicians, vendors, manufacturers, beneficiaries, caregivers, etc.) can make presentations of information related to the proposed LCDs”

How Do you Find a Medicare LCD for Your Jurisdiction?

The Medicare Administrative Contractors are listed below as of October 2021 by State, Jurisdiction, and the name of the MAC:

 

State Jurisdiction (J) Medicare Administrative Contractor (MAC)
Alabama DME MAC – JC CGS Administrators, LLC
A/B MAC – JJ Palmetto GBA, LLC
HH + H MAC – JM Palmetto GBA, LLC
Alaska DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JF Noridian Healthcare Solutions, LLC
HH+ H MAC – J6 National Government Services, Inc.
American Samoa DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JE Noridian Healthcare Solutions, LLC
HH + H MAC – J6 National Government Services, Inc.
Arizona DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JF Noridian Healthcare Solutions, LLC
HH + H MAC – J6 National Government Services, Inc.
Arkansas DME MAC – JC CGS Administrators, LLC
A/B MAC – JH Novitas Solutions, Inc.
HH + H MAC – JM Palmetto GBA, LLC
California DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JE Noridian Healthcare Solutions, LLC
HH + H MAC – J6 National Government Services, Inc.
Colorado DME MAC – JC CGS Administrators, LLC
A/B MAC – JH Novitas Solutions, Inc.
HH + H MAC – J15 CGS Administrators, LLC
Connecticut DME MAC – JA Noridian Healthcare Solutions, LLC
A/B MAC – JK National Government Services, Inc.
HH + H MAC – JK National Government Services, Inc.
Delaware DME MAC – JA Noridian Healthcare Solutions, LLC
A/B MAC – JL Novitas Solutions, Inc.
HH + H MAC – J15 CGS Administrators, LLC
District of Columbia DME MAC – JA Noridian Healthcare Solutions, LLC
A/B MAC – JL Novitas Solutions, Inc.
HH + H MAC – J15 CGS Administrators, LLC
Florida DME MAC – JC CGS Administrators, LLC
A/B MAC – JN First Coast Service Options, Inc.
HH + H MAC – JM Palmetto GBA, LLC
Georgia DME MAC – JC CGS Administrators, LLC
A/B MAC – JJ Palmetto GBA, LLC
HH + H MAC – JM Palmetto GBA, LLC
Guam DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JE Noridian Healthcare Solutions, LLC
HH + H MAC – J6 National Government Services, Inc.
Hawaii DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JE Noridian Healthcare Solutions, LLC
HH + H MAC – J6 National Government Services, Inc.
Idaho DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JF Noridian Healthcare Solutions, LLC
HH + H MAC – J6 National Government Services, Inc.
Illinois DME MAC – JB CGS Administrators, LLC
A/B MAC – J6 National Government Services, Inc.
HH + H MAC – JM Palmetto GBA, LLC
Indiana DME MAC – JB CGS Administrators, LLC
A/B MAC – J8 Wisconsin Physicians Service Government Health Administrators
HH + H MAC – JM Palmetto GBA, LLC
Iowa DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – J5 Wisconsin Physicians Service Government Health Administrators
HH + H MAC – J15 CGS Administrators, LLC
Kansas DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – J5 Wisconsin Physicians Service Government Health Administrators
HH + H MAC – J15 CGS Administrators, LLC
Kentucky DME MAC – JB CGS Administrators, LLC
A/B MAC – J15 CGS Administrators, LLC
HH + H MAC – JM Palmetto GBA, LLC
Louisiana DME MAC – JC CGS Administrators, LLC
A/B MAC – JH Novitas Solutions, Inc.
HH + H MAC – JM Palmetto GBA, LLC
Maine DME MAC – JA Noridian Healthcare Solutions, LLC
A/B MAC – JK National Government Services, Inc.
HH + H MAC – JK National Government Services, Inc.
Maryland DME MAC – JA Noridian Healthcare Solutions, LLC
A/B MAC – JL Novitas Solutions, Inc.
HH + H MAC – J15 CGS Administrators, LLC
Massachusetts DME MAC – JA Noridian Healthcare Solutions, LLC
A/B MAC – JK National Government Services, Inc.
HH + H MAC – JK National Government Services, Inc.
Michigan DME MAC – JB CGS Administrators, LLC
A/B MAC – J8 Wisconsin Physicians Service Government Health Administrators
HH + H MAC – J6 National Government Services, Inc.
Minnesota DME MAC – JB CGS Administrators, LLC
A/B MAC – J6 National Government Services, Inc.
HH + H MAC – J6 National Government Services, Inc.
Mississippi DME MAC – JC CGS Administrators, LLC
A/B MAC – JH Novitas Solutions, Inc.
HH + H MAC – JM Palmetto GBA, LLC
Missouri DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – J5 Wisconsin Physicians Service Government Health Administrators
HH + H MAC – J15 CGS Administrators, LLC
Montana DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JF Noridian Healthcare Solutions, LLC
HH + H MAC – J15 CGS Administrators, LLC
Nebraska DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – J5 Wisconsin Physicians Service Government Health Administrators
HH + H MAC – J15 CGS Administrators, LLC
Nevada DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JE Noridian Healthcare Solutions, LLC
HH + H MAC – J6 National Government Services, Inc.
New Hampshire DME MAC – JA Noridian Healthcare Solutions, LLC
A/B MAC – JK National Government Services, Inc.
HH + H MAC – JK National Government Services, Inc.
New Jersey DME MAC – JA Noridian Healthcare Solutions, LLC
A/B MAC – JL Novitas Solutions, Inc.
HH + H MAC – J6 National Government Services, Inc.
New Mexico DME MAC – JC CGS Administrators, LLC
A/B MAC – JH Novitas Solutions, Inc.
HH + H MAC – JM Palmetto GBA, LLC
New York DME MAC – JA Noridian Healthcare Solutions, LLC
A/B MAC – JK National Government Services, Inc.
HH + H MAC – J6 National Government Services, Inc.
North Carolina DME MAC – JC CGS Administrators, LLC
A/B MAC – JM Palmetto GBA, LLC
HH + H MAC – JM Palmetto GBA, LLC
North Dakota DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JF Noridian Healthcare Solutions, LLC
HH + H MAC – J15 CGS Administrators, LLC
Northern Mariana Islands DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JE Noridian Healthcare Solutions, LLC
HH + H MAC – J6 National Government Services, Inc.
Ohio DME MAC – JB CGS Administrators, LLC
A/B MAC – J15 CGS Administrators, LLC
HH + H MAC – JM Palmetto GBA, LLC
Oklahoma DME MAC – JC CGS Administrators, LLC
A/B MAC – JH Novitas Solutions, Inc.
HH + H MAC – JM Palmetto GBA, LLC
Oregon DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JF Noridian Healthcare Solutions, LLC
HH + H MAC – J6 National Government Services, Inc.
Pennsylvania DME MAC – JA Noridian Healthcare Solutions, LLC
A/B MAC – JL Novitas Solutions, Inc.
HH + H MAC – J15 CGS Administrators, LLC
Puerto Rico DME MAC – JC CGS Administrators, LLC
A/B MAC – JN First Coast Service Options, Inc.
HH + H MAC – J6 National Government Services, Inc.
Rhode Island DME MAC – JA Noridian Healthcare Solutions, LLC
A/B MAC – JK National Government Services, Inc.
HH + H MAC – JK National Government Services, Inc.
South Carolina DME MAC – JC CGS Administrators, LLC
A/B MAC – JM Palmetto GBA, LLC
HH + H MAC – J M Palmetto GBA, LLC
South Dakota DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JF Noridian Healthcare Solutions, LLC
HH + H MAC – J15 CGS Administrators, LLC
Tennessee DME MAC – JC CGS Administrators, LLC
A/B MAC – JJ Palmetto GBA, LLC
HH + H MAC – JM Palmetto GBA, LLC
Texas DME MAC – JC CGS Administrators, LLC
A/B MAC – JH Novitas Solutions, Inc.
HH + H MAC – JM Palmetto GBA, LLC
Utah DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JF Noridian Healthcare Solutions, LLC
HH + H MAC – J15 CGS Administrators, LLC
Vermont DME MAC – JA Noridian Healthcare Solutions, LLC
A/B MAC – JK National Government Services, Inc.
HH + H MAC – JK National Government Services, Inc.
Virgin Islands DME MAC – JC CGS Administrators, LLC
A/B MAC – JN First Coast Service Options, Inc.
HH + H MAC – J6 National Government Services, Inc.
Virginia DME MAC – JC CGS Administrators, LLC
A/B MAC – JL Novitas Solutions, Inc.
(includes Part B for counties of Arlington and Fairfax, and the city of Alexandria)
A/B MAC – JM Palmetto GBA, LLC
(excludes Part B for the counties of Arlington and Fairfax, and the city of Alexandria) CGS Administrators, LLC
HH + H MAC – J15
Washington DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JF Noridian Healthcare Solutions, LLC
HH + H MAC – J6 National Government Services, Inc.
West Virginia DME MAC – JC CGS Administrators, LLC
A/B MAC – JM Palmetto GBA, LLC
HH + H MAC – J15 CGS Administrators, LLC
Wisconsin DME MAC – JB CGS Administrators, LLC
A/B MAC – J6 National Government Services, Inc.
HH + H MAC – J6 National Government Services, Inc.
Wyoming DME MAC – JD Noridian Healthcare Solutions, LLC
A/B MAC – JF Noridian Healthcare Solutions, LLC
HH + H MAC – J15 CGS Administrators, LLC

 

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Medicare LCD and Rule Making Modernization

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Medical Coding Expert Witness

Medicare Fraud Expert Witness

Medicare LCD Coverage Database

Merit-Based Incentive Program (MIPS)

Promoting Interoperability