National Coverage and Medical Review Policy


The Centers for Medicare and Medicaid Services (CMS) has established National Coverage Determinations (NCD) and allows local carriers to establish Local Coverage Determinations (LCD). Certain tests are then "targeted" and subsequently require proof of medical necessity in the form of specific ICD-10-CM diagnosis code(s). CMS has authorized Medicare carriers to deny payment for laboratory services on the basis of NCD and LCD guidelines.

Please contact our Client Service Department for the latest list of "targeted" tests and frequency guidelines.

 
Medicare Local Coverage Determinations (LCD)

 

Medical Necessity Requirements by Payer

 

Aetna Reimbursement Policy 

Buckeye Medicaid
Managed Health Services
Ambetter of Indiana

   

Medical Necessity Requirements Following Medicare

 

The following Insurance plans follow Medicare (CMS) LCD/NCD guidelines. The CMS NCD/LCD resources can be used to identify testing and diagnosis that will be affected by this policy.

  • Advantra Coventry
  • Aetna Medicare
  • Anthem Medicare
  • Humana Medicare
  • Molina Medicaid
  • Molina Medicare
  • United Health Care Medicare (Secure Horizons)