NCDs vs LCDs: How Medicare Coverage Determinations Work

2026-08-03 · Caduvo Team

Learn the hierarchy of Medicare coverage decisions, how to search the Medicare Coverage Database, and what to do when no policy exists—practical guidance for market access teams.

Your device has FDA clearance. You have a billing code. But Medicare won’t pay. That’s the moment market access teams realize coverage is not automatic. Medicare decides what it will pay for through National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). Knowing the difference—and how to research them—shapes your entire market access strategy.

The NCD–LCD Hierarchy: National vs. Local

A national coverage determination (NCD) is a binding policy issued by CMS. It applies to all Medicare contractors and all beneficiaries nationwide. Once an NCD is in place, no local coverage determination can override or contradict it.

A local coverage determination (LCD) is issued by a Medicare Administrative Contractor (MAC). LCDs only apply within the MAC’s multi-state jurisdiction. If no NCD exists for a service or item, a MAC can decide whether to cover it and under what conditions. LCDs often fill gaps left by the absence of an NCD.

This hierarchy is strict: NCDs preempt LCDs. If a MAC wants to deviate from an NCD, it must first get CMS permission. Practically, that means your coverage landscape starts with a check for any relevant NCD. If one exists, it’s the floor and ceiling. If none exists, you’ll be navigating up to 12 different LCDs—one from each MAC.

Medicare Administrative Contractors and Their Role

MACs are private insurers that Medicare pays to process Part A and Part B claims. They have two core functions: claims adjudication and medical policy development. That policy arm is where LCDs come from.

Each MAC covers a defined region. For example, Novitas Solutions handles J-H and J-L, while NGS covers J-6 and J-K. A device company selling nationally will encounter multiple MACs, each with its own LCDs, claim edits, and medical director priorities.

MACs have medical directors who lead policy development. These clinical leads review evidence, hold open meetings, and sometimes publish draft LCDs for comment. If a procedure or device falls under an overly restrictive LCD, the medical director is often the person who can open a reconsideration. A well-prepared dossier of clinical evidence, cost-effectiveness data, and specialty society endorsements can lead to a revised LCD—or a new one where none existed.

If you’re seeing inconsistent claim outcomes across regions, the root cause is almost always a local coverage determination.

Searching the Medicare Coverage Database

The Medicare Coverage Database (MCD) is the single source for all NCDs and LCDs. It’s freely available on the CMS website. Start here:

• Go to the MCD search page.
• Enter a CPT or HCPCS code, a keyword, or a diagnosis code.
• Filter by document type: NCD or LCD.

A single code can appear in multiple LCDs. For example, HCPCS code L8699 (miscellaneous prosthetic) might show up in an extremity prosthetic LCD from one MAC and a lower-limb LCD from another. The MCD shows each document’s effective date, revision history, and the specific indications or limitations.

NCDs are labeled with the prefix “NCD” and typically have a full analysis section. LCDs include the MAC name and jurisdiction. If a code returns no results, it means no national or local policy has been published. That doesn’t mean coverage is denied—it means coverage is at the discretion of the MAC’s “reasonable and necessary” judgment on a claim-by-claim basis.

Caduvo continuously monitors coverage policies across all MAC jurisdictions, so manufacturers can stay ahead of changes without manual searches.

What to Do When Coverage Is Absent or Restrictive

An absent LCD isn’t a dead end—it’s an opening. When no policy exists, claims are adjudicated under broad Medicare rules: the service must be “reasonable and necessary” for the diagnosis or treatment of illness or injury. But without a written policy, you’ll face inconsistency.

Here’s the typical playbook:

• Build the evidence docket. MAC medical directors respond to peer-reviewed studies, registry data, and clinical guidelines. Retrospective claims analyses showing cost offsets can also move the needle.
• Request a meeting. Most MACs accept requests from manufacturers to discuss new technologies. Bring a summary of the technology, the evidence, and a proposed coverage framework.
• Pursue a local coverage determination. Submit a formal reconsideration request if an existing LCD is too restrictive, or a new LCD request if none exists. Each MAC has a published process.
• Monitor contractor advisory committee (CAC) opportunities. Some MACs convene CACs to get external input on new technologies. Securing a presentation slot can raise visibility.
• Consider the national route carefully. A national coverage determination request is a heavy lift—it requires substantial evidence, often a technology assessment, and can take years. Most device companies start locally.

For devices that have received Breakthrough Device designation from the FDA, there is a separate pathway through the Transitional Coverage for Emerging Technologies (TCET) initiative. Breakthrough device designation creates a formal channel for early dialogue with CMS, though coverage is not guaranteed.

If coverage is restrictive, the same evidence-building approach applies, but you may also need to engage specialty societies to advocate for policy revision. MAC medical directors pay close attention to input from the clinicians they serve.

Actionable Takeaways

• Search the Medicare Coverage Database for any NCD first; then search each MAC jurisdiction for relevant LCDs.
• Map your target geographies to specific MACs so you know which policies affect you.
• If no policy exists, build a clinical evidence package and engage the MAC medical director early.
• Track LCD draft openings—they are windows to comment and shape policy.
• For breakthrough technologies, explore the TCET pathway as a parallel track to local engagement.