Medicare Coverage Determination Process

Original Medicare is meant to cover items, treatments and services that are medically necessary. A nine-month process determines the final decision. The first phase of the process lasts six months.

Determining Medicare coverage is a strict and exhaustive process. After the first six months, a potential determination enters its second phase of review.

This additional phase lasts three months, including one month that serves as a public comments phase.

Afterwards, two essential milestones occur in the next allotted 60 days: the completion of a final decision memorandum and an implementation plan for the new coverage guidelines.

The process would generally end there, but there is also a chance for a reconsideration phase before a final decision.

Original Medicare will cover anything that does not meet all three of these requirements.

Coverage is still possible through a Medicare Advantage plan. These plans, which private insurers provide, cover everything included in Original Medicare and additional benefits.

A national coverage determination (NCD) decides coverage for a treatment or service that applies to the entire nation. An NCD is also determined through a nine-month process.

If there is no NCD for a treatment, service or item that you want to receive coverage for, a formal request can be made to initiate the process.

Coverage could also be available through a local coverage determination even if there is not an NCD.

A local coverage determination, which applies to a specific geographic area, can cover an item or service not included in an NCD.

An LCD cannot contradict or offer less coverage than an NCD but can include expanded coverage for a treatment or service.