What is a National Coverage Determination (NCD)?
The Secretary of the Department of Health and Human Services determines whether or not a particular item or service is covered nationally by Medicare. The formal name for this process, which essentially grants, limits, or excludes Medicare coverage, is the National Coverage Determination (NCD). NCDs are binding on all Medicare carriers, fiscal intermediaries, quality improvement organizations, health maintenance organizations, competitive medical plans and health care prepayment plans.
Who can request a NCD?
Anyone can request a national coverage determination from the Centers for Medicare and Medicaid Services (CMS), however "aggrieved" beneficiaries, defined by CMS as "individuals entitled to benefits under Part A, or enrolled under Part B, or both, who are in need of the items or services that are the subject of the coverage determination", are given priority for requesting a NCD. CMS has outlined a specific process for requesting a NCD, which takes approximately 9 months from the date the complete NCD request is received by CMS to the date that coverage changes are implemented. For an outline of the Medicare National Coverage Process, Click here.
How can I look up a NCD?
There is an online database maintained by the Centers for Medicare and Medicaid Services (CMS) available to the public for NCD searches that can be accessed here.
What is the MCAC?
The Medicare Coverage Advisory Committee (MCAC) advises CMS on whether specific medical items and services are reasonable and necessary under Medicare law related to certain NCD submissions. The MCAC adds to CMS's internal groups that analyze NCD requests. The MCAC performs a detailed analysis and provides comments regarding specific clinical and scientific issues in an open and public forum. Although the MCAC participates in certain NCD reviews, they are advisory in nature, as the final decision on all coverage issues is made by CMS.
CMS selects members of the MCAC based on their background, education, and expertise in a wide variety of scientific, clinical, and other related fields. In composing the MCAC, CMS looks at ethnicity, gender, geography, and other diverse views, and screens each member to determine potential conflicts of interest. There are currently two radiologyand one radiation oncology representatives on the MCAC.