Medicare Coverage Determination Process

The deciding factor for whether Medicare will cover a treatment, service or item is if it can be considered medically necessary. This process includes a multi-step, nine-month evaluation of the requests for coverage, which can result in the creation of a national coverage determination.

What Is the Medicare 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.

The First 6 Months of the Medicare National Coverage Process
  • Preliminary Discussions
  • Benefit Category
  • National Coverage Request
  • Staff Review
  • External Technology Assessment or Medicare Coverage Advisory Committee
  • Second Staff Review
  • Decision Posted

Determining 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.

What is Reasonable and Necessary?

There are three qualifications that Medicare uses to determine if a treatment or service is medically necessary. Treatments, items or services must be:
  • Proven to be safe and effective
  • Non-experimental or non-investigational
  • Appropriate for Medicare patients

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.

National Coverage Determinations (NCDs)

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.

Local Coverage Determinations (LCDs)

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.

Last Modified: August 5, 2021

7 Cited Research Articles

  1. American Hospital Association. (2021, January 13). CMS codifies definition of ‘reasonable and necessary’ Medicare coverage. Retrieved from https://www.aha.org/news/headline/2021-01-13-cms-codifies-definition-reasonable-and-necessary-medicare-coverage
  2. U.S. Centers for Medicare & Medicaid Services. (2021, January 12). Medicare Coverage of Innovative Technology. Retrieved from https://www.cms.gov/newsroom/fact-sheets/medicare-coverage-innovative-technology-cms-3372-f
  3. U.S. Centers for Medicare & Medicaid Services. (2003, September 26). Revised Process for Making Medicare National Coverage Determinations. Retrieved from https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads//FR09262003.pdf
  4. U.S. Centers for Medicare & Medicaid Services. (n.d.). Local Coverage Determinations. Retrieved from https://www.cms.gov/Medicare/Coverage/DeterminationProcess/LCDs
  5. U.S. Centers for Medicare & Medicaid Services. (n.d.). Local Coverage Determinations (LCD) Challenge. Retrieved from https://www.medicare.gov/claims-appeals/local-coverage-determinations-lcd-challenge
  6. U.S. Centers for Medicare & Medicaid Services. (n.d.). Medicare Coverage Determination Process. Retrieved from https://www.cms.gov/Medicare/Coverage/DeterminationProcess
  7. U.S. Centers for Medicare & Medicaid Services. (n.d.). Medicare National Coverage Process. Retrieved from https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/8a.pdf