NCDs vs LCDs: How Medicare Coverage Determinations Work and How to Research Them
2026-07-10 · Caduvo Team
Medtech market access starts with understanding Medicare's two-tier coverage system. This post explains NCDs, LCDs, MACs, and how to research existing policies using the Medicare Coverage Database.
Your device has FDA clearance. The clinical data is strong. But when the first patient tries to get it covered by Medicare, the claim is denied. Why? Because in the U.S., regulatory approval does not equal reimbursement. Medicare, which covers roughly 64 million Americans, has its own two-tier system for deciding what it will pay for. Understanding that system—and how to research it—is not optional. It's the foundation of market access.
National Coverage Determinations vs Local Coverage Determinations
Medicare coverage policy operates through two main pathways: National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). The hierarchy is straightforward: NCDs are issued by CMS and are binding on all Medicare Administrative Contractors (MACs). LCDs are issued by the 12 regional MACs and apply only within their specific jurisdictions. When no NCD exists, MACs may develop LCDs or make case-by-case decisions on individual claims.
NCDs are relatively rare. They go through a formal evidence-development process called a National Coverage Analysis (NCA). An NCD can be initiated by CMS, requested by an external party (such as a device manufacturer or professional society), or triggered by a new technology. For example, CMS’s NCD for implantable cardioverter defibrillators (NCD 20.4) spells out exactly which patients qualify: those with ischemic or non-ischemic dilated cardiomyopathy, a left ventricular ejection fraction ≤35%, and NYHA Class II or III heart failure. If your device doesn’t match those criteria, Medicare won’t pay—period.
LCDs fill the gaps. MACs issue LCDs when a service or device is not addressed by an NCD and they determine that uniform payment rules are needed. An LCD might cover a novel biomarker test, a particular spinal procedure, or a remote therapeutic monitoring service. For instance, multiple MACs have LCDs for peripheral nerve stimulation that list required diagnoses (e.g., chronic intractable pain), prior conservative treatments (e.g., physical therapy, medication), and device specifications. These criteria can vary by MAC, so a device that meets one contractor’s standard might still be denied in another jurisdiction.
Where to Find Policies: The Medicare Coverage Database
The official source is the Medicare Coverage Database (MCD) at cms.gov/medicare-coverage-database. It contains all NCDs, LCDs, and related policy articles. To search, enter a keyword, CPT/HCPCS code, or diagnosis code. You can filter by document type (NCD, LCD), status (active, retired), and state or MAC region.
A practical example: search “remote patient monitoring.” The results will show NCD 20.19 (Remote Physiologic Monitoring) and several active LCDs from different MACs. Clicking into an LCD reveals the full coverage guidance: covered indications, limitations, documentation requirements, and ICES (ICD-10 codes that support medical necessity). Always check the effective date—LCDs are updated periodically, and new versions can add or remove coverage.
Note that MACs also maintain their own websites with additional local articles and billing guides that may not appear in the MCD. So after your MCD search, cross-reference the relevant MAC’s site. If you’re using a specific code to search, make sure you understand the distinction between HCPCS and CPT codes — many devices use HCPCS Level II codes rather than CPT.
What to Do When Coverage Is Absent, Inconsistent, or Restrictive
No NCD or LCD exists. This is common for truly novel technologies. Without any coverage policy, claims may be paid on a case-by-case basis, but denials are frequent. Your primary strategy: request that one or more MACs consider developing an LCD. Submit a formal request to the MAC’s Contractor Medical Director, supported by published clinical evidence and professional society guidelines. If you need a national policy, you can petition CMS for an NCD, but the process is lengthy and resource-intensive.
An existing LCD is too restrictive. Perhaps the LCD lists covered indications that don’t match your device’s FDA-approved labeling, or it imposes documentation hurdles that hinder adoption. You can ask the MAC to revise the LCD. This means engaging the Contractor Medical Director, presenting your clinical data, and showing how the current policy limits patient access. Be prepared for a multi-month review.
Multiple MACs have conflicting LCDs. When LCDs diverge, you face a patchwork of coverage criteria. Mapping all variations manually is tedious. Platforms like Caduvo pull every relevant LCD across all jurisdictions and highlight differences, saving you from spreadsheet chaos. Once you understand the inconsistencies, you can decide whether to pursue an NCD to standardize coverage nationally.
In all cases, remember that coding is a prerequisite. Without an appropriate HCPCS code or CPT code, you cannot submit a compliant claim. So establish your coding pathway before you tackle coverage.
Actionable Steps for Market Access Teams
- Scan the Medicare Coverage Database early—ideally during regulatory planning. Know what NCDs and LCDs exist for your technology category.
- If you have a target HCPCS code, use it to pull every active LCD. Repeat for related codes or keywords to catch policies under different numbers.
- Compare LCD criteria across all MACs that would process claims from high-volume physician practices in your target regions.
- When no coverage exists, prepare a clinical evidence package and initiate dialog with the MAC’s medical director.
- For restrictive policies, quantify the gap—e.g., which patient subgroups are excluded—and build a data-driven argument for revision.
- Monitor the MCD quarterly for new or retired LCDs that could open or close windows of opportunity.
- Align your coding strategy early; coverage discussions are futile without a billable code.