Public Healthcare Benefit Plans

	Research study cited in a public insurance determination in support of coverage.

The Centers for Medicare & Medicaid Services (CMS) provides public healthcare coverage for items and services for over 43 million beneficiaries. The vast majority of coverage is provided on a local level, through local coverage determinations (LCD). However, in certain cases, Medicare deems it appropriate to develop a national coverage determination (NCD) for an item or service to be applied on a national basis for all Medicare beneficiaries meeting the criteria for coverage.

Public Insurance – National Coverage Determinations

National Coverage Determinations (NCDs) are issued by CMS to provide guidance to assist providers in submitting correct claims for payment. NCDs apply to all Medicare jurisdictions. The impetus for NCD development can come from different sectors, such as provider groups and beneficiary advocate groups, often working through legislative channels.

Public Insurance – Local Coverage Determinations

LCDs are contractor-developed coverage policies, pertaining to services or items not addressed in National Coverage Determinations (NCDs) or program manuals. Local Coverage Determinations (LCD) provide guidance to assist providers in submitting correct claims for payment, and contain coding and utilization guidelines. Some of the important issues addressed in a LCD are:

• Which services are covered and reimbursable
• How to properly code the services provided
• Documentation requirements
• Utilization guidelines
• ICD-9 Codes that support or do not support medical necessity

For example, some LCDs include references that serve as the basis for decision of coverage. For example, one LCD for Corneal Pachymetry notes two publications (Gordon and Brandt) from the Ocular Hypertension Treatment Study (OHTS) as support for coverage of pachymetry as well as a trade publication (Parrish) article that summarizes the OHTS findings.

Assessment

Review of NCDs and LCDs is required to locate evidence that findings from a research study were used as support for implementation of a coverage decision. Review of the literature can also be helpful in locating evidence of clinical implementation from research study findings noted in NCDs AND LCDs. For resources that may be helpful for review of the literature, see Knowledge Transfer: Mass Media and Knowledge Transfer: Reviews.

	Follow the directions for searching as noted on the Medicare Coverage Database.

The following resource is also useful for locating NCDs and LCDs:

Medicare Coverage Database of National Coverage Documents (NCDs) and Local Coverage Determinations (LCDs)

The Medicare Coverage Database (MCD) contains all National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), local policy articles, and proposed NCD decisions. The database also includes several other types of national coverage policy related documents, including national coverage analyses (NCAs), coding analyses for labs (CALs), Medicare Evidence Development & Coverage Advisory Committee (MedCAC) proceedings, and Medicare coverage guidance documents. The MCD offers multiple ways to locate and view data:

• Search – Allows users to search both the NCD and LCD databases using a variety of criteria such as key word, coverage topic, and date.
• Indexes – Provides users with pre-defined lists of national and local coverage documents.
• Reports – Provides users with reports of national and local coverage data.
• Download – Allows users to download complete sets of LCDs and articles and the complete set of NCDs

Medicare Coverage Database Search interface

 

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Last updated: May 4, 2009