Medicare has determined that certain tests are subject to NCD and LCD limitations.
- NCD - National Coverage Determination
- LCD - Local Coverage Determination
In short, Medicare is limiting the amount of a certain test/supply/service that they will cover for a patient for a period of time. These determinations can be made for all Medicare patients on a national level (NCD) or by the Medicare MAC (Medicare Administrative Contractors) on a local level (LCD).
Tests can be limited by frequency (only X number allowed in X amount of years) or by medical necessity (must have X diagnosis for X test to be covered).
Examples of this include:
- NDC for CBC (Complete Blood Count) - Only covered by Medicare when the patient has a certain listed diagnosis code.
- NDC for Lipid Panels - Only covered by Medicare when the patient has a certain listed diagnosis code. It can be ordered up to 6 times during the first year of diagnosis to measure treatment efforts. Once treatment goals have been reached, lipid testing is only covered 3 times per year.
A Local Coverage Determination is made by Medicare MACs (Medicare Administrative Contractors).
- LCD exists for Novitas (MAC for Washington DC, Delaware, Maryland, New Jersey, and Pennsylvania) for Allergy Testing. There are certain conditions a patient must have for allergy testing to be covered. The LCD also states that percutaneous testing (scratch, puncture, prick) testing is preferred over patch, photo patch, photo testing, or intradermal testing.
- LCD exists for Novitas (MAC for Washington DC, Delaware, Maryland, New Jersey, and Pennsylvania) for Ground Ambulance Services. Services are only covered if one of the three situations exists if the patient was transported via a different mode of transportation: (1) Place the patient's health in serious jeopardy, (2) Cause serious impairment to bodily functions, or (3) Cause serious dysfunction of any body organ or part.
The Medicare coverage database lists both current and retired NCDs and LCDs. It is important that providers know if any services they order/provide to their patients are covered under an NCD or LCD.
https://www.cms.gov/medicare-coverage-database/search.aspx
The patient can still have the service/test/item, but they will be asked to sign an ABN (Advance Beneficiary Notice) and be expected to pay for the services themselves. Typically, if Medicare will not pay for the test/item/service due to an NCD or LCD, any secondary or tertiary insurance will also deny.