Coverage

NCDNational Coverage Determinations

National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation.

Need more information? The Centers for Medicare and Medicaid Services (CMS) has guidance documents containing detailed information on the process and decision-making factors to assist parties or organizations that may request an NCD.

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National Coverage Determinations (NCDs) are binding on all Medicare contractors, quality improvement organizations, health maintenance organizations, competitive medical plans and healthcare prepayment plans. The Secretary of the Department of Health and Human Services determines whether a particular item or service is covered nationally by Medicare, which essentially grants, limits or excludes national coverage to all Medicare beneficiaries. These determinations are binding on all Medicare contractors and outline the conditions for which a service is covered or not covered. These determinations are based on evidence, including medical and scientific information, FDA data, and clinical trial information.

Anyone can request an NCD from CMS. However, "aggrieved" beneficiaries, defined 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.

CMS has outlined a specific process, which takes nine months or more from the date the complete request is received by CMS to the date that coverage changes are implemented.

The Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) advises CMS on whether specific medical items and services are reasonable and necessary under Medicare law related to certain NCD submissions. MEDCAC performs a detailed analysis and provides comments regarding specific clinical and scientific issues in an open and public forum but CMS makes the final decision on coverage issues.

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LCDLocal Coverage Determination

In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).

Need more information? The Centers for Medicare and Medicaid Services (CMS) provides additional guidance.

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An LCD, as defined in §1869(f)(2)(B) of the Social Security Act (SSA), is a determination by a Medicare Administrative Contractor (MAC) regarding whether or not a particular item or service is covered on a contractor–wide basis in accordance with section 1862(a)(1)(A) of the Act. Medicare Administrative Contractors (MACs) establish LCDs.

90% of Medicare policies are established at the local level, providing contractors with tremendous authority over payment policy in a given state. Representatives of the ACR® Radiology, Radiation Oncology and Nuclear Medicine Contractor Advisory Committee (CAC) Network advocate on behalf of radiology for fair reimbursement policies at the local Medicare level.

By reviewing and commenting on Local Coverage Decisions (LCDs) and proposed policy changes, the CAC networks help ensure that members are appropriately reimbursed for medically reasonable and necessary services provided to Medicare patients.

When a Medicare contractor develops a new LCD or significantly revises an existing one, a 45-day public comment period is required. During this time, Contractor Medical Directors (CMDs) solicit input from members of the CAC. Comments can be submitted to the CMD or electronically through your Medicare contractor's website. After the CMDs have considered all comments received, there is a 45-day notice period prior to implementation of the final LCD. Providers and billing staff should track LCD changes using the Medicare Coverage Database. The Centers for Medicare and Medicaid Services (CMS) has revised rules for the development and administration of Medicare Local coverage determinations (LCDs).

Trigger Point Injections (TPI)
Sacroiliac Joint Injections and Procedures
Magnetic Resonance Imaging of the Head and Neck
CT Perfusion Analysis
Radiation Therapy
Proton Beam Radiotherapy
Intensity Modulated Radiation Therapy (IMRT)
SRT for Non-Melanoma Skin Cancers
Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease
Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT)/Coronary Plaque Analysis (AI-CPA)
CT Colonography (NCD)
Transitional Coverage for Emerging Technologies (NCD).

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What is the CAC Network?

The ACR CAC Network was developed to encourage communication and coordination among all radiology CAC representatives. The ACR is committed to providing as much assistance as possible to each CAC representative. Adoption of the ACR CAC Networks include representatives and alternates appointed by the state chapters created a more organized and effective mechanism for dealing with local Medicare issues. State Chapter leaders should notify ACR staff of changes to CAC representatives and alternates.

Join the ACR CAC Network and Champion Radiology’s Voice in Medicare Policy

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140

ACR CAC Network members

CAC Network meetings per year

5-10

Supported multispecialty society letters annually addressing coverage determination concerns

Medicare Part A and Part B MACs processing claims across 12 jurisdictions

51%

of the total Medicare beneficiary population utilizes Medicare Fee for Service

million individuals receive Medicare FFS benefits

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Questions

Regarding the CAC Network at ACR?

Email Alicia Blakey

Additional Resources

Feb. 21, 2025 – ACR, Others Challenge MAC Position on Minimally Invasive Arthrodesis of the Sacroiliac Joint
Feb. 18, 2025 – Radiology Societies Challenge Washington State VKS Evidence Review
Oct. 4, 2024 – ACR Pans CMS Consideration of MAC Consolidation
July 16, 2024 – ACR Provides Recommendations on Cures 2.0 Legislative Policies
Dec. 12, 2023 – CMS Leadership Responds to Issues Raised by Multi-Specialty CAC Engagement Coalition

These principles are developed by the ACR and 18 organizations to strengthen the local coverage determination process and engagement of our members with Medicare contractors.

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CMS Coverage Resources

Local Coverage Determinations (LCDs)

MLN Matters 1090

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Medicare Coverage Database

The Medicare Coverage Database (MCD) is a resource for viewing policies and articles related to Medicare coverage.

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Medicare Program Integrity Manual

Chapter 13 — Local Coverage Determinations

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Interested in joining the Contractor Advisory Committee?

Explore opportunities

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NCDNational Coverage Determinations

Learn more

Medicare Coverage Activities: How ACR Helps Your Practice

NCDNational Coverage Determinations

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LCDLocal Coverage Determination

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What is the CAC Network?

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Questions

Additional Resources

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CMS Coverage Resources

Interested in joining the Contractor Advisory Committee?

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NCDNational Coverage Determinations

LCDLocal Coverage Determination

Questions

Additional Resources

CMS Coverage Resources

Interested in joining the Contractor Advisory Committee?

Get the Latest ACR News

Medicare Coverage Activities: How ACR Helps Your Practice

NCDNational Coverage Determinations

What is an NCD?

Who can request an NCD?

What is the process for requesting an NCD?

What is MEDCAC?

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LCDLocal Coverage Determination

What is an LCD

Why this matters

How the LCD Process Works

Topics for Review 2024-2025

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What is the CAC Network?

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Questions

Additional Resources

ACR Policy Letters

Principles for Sound Local Coverage Policies

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CMS Coverage Resources

Interested in joining the Contractor Advisory Committee?

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NCDNational Coverage Determinations

What is an NCD?

Who can request an NCD?

What is the process for requesting an NCD?

What is MEDCAC?

LCDLocal Coverage Determination

What is an LCD

Why this matters

How the LCD Process Works

Topics for Review 2024-2025

Questions

Additional Resources

ACR Policy Letters

Principles for Sound Local Coverage Policies

CMS Coverage Resources

Interested in joining the Contractor Advisory Committee?

Get the Latest ACR News