A national coverage determination (NCD) is a United States nationwide determination of whether Medicare will pay for an item or service. When an NCD currently exists, any individual or entity may request that we reconsider any provision of that NCD by filing a complete formal request for reconsideration.
In August 2013, the Centers for Medicare & Medicaid Services (CMS) published a Federal Register notice, (78 FR 48164-69), updating the process used for opening, deciding or reconsidering NCDs under the Social Security Act.1
Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury. The 2013 notice further outlined an expedited administrative process to remove certain NCDs older than 10 years since their most recent review, thereby enabling local Medicare contractors to determine coverage.1
Similar to a request for a new NCD, the request for reconsideration must be submitted in writing and be clearly identified. Medicare will consider accepting a request to revise an existing NCD, if the requester presents documentation of additional scientific evidence, which was not considered during the most recent review, with a sound premise that new evidence may change the NCD decision. Otherwise a requester will need to make plausible arguments that Medicare materially misinterpreted the existing evidence at the time the NCD was decided.1
As with a request for a new NCD, a reconsideration request must meet the following conditions:
The requester provides a final letter of request and clearly identifies the request as a ‘‘Formal Request for NCD Reconsideration.’’
The requester identifies the scientific evidence that supports the request for reconsideration
The written request includes and supports any additional Medicare Part A or Part B benefit categories in which the requester believes the item or service falls.
The request includes supporting documentation and is received electronically Medicare will review materials presented in a complete, formal request by the requester.1
Medicare review is not limited to the materials submitted by the requester, other related clinical materials will be reviewed before the request is accepted for reconsideration. Medicare will make a decision to accept or reject an external NCD reconsideration request within 60 days of receipt. If Medicare accepts the reconsideration request, the letter requesting reconsideration will be posted with a tracking sheet announcing that a reconsideration of the NCD has begun. If they decline the request, CMS will send a letter to the requester, rejecting the reconsideration request.1
90 percent of Medicare coverage decisions are established at the local level, providing contractors with immense authority over payment policy in a given state.2
CMS may also internally open a reconsideration of any policy or of an entire NCD. Generally, an internal NCD reconsideration is initiated because of new evidence that could support a material change in coverage.1
Department of Health and Human Services. Revised Process For Making National Coverage Determinations. Baltimore Maryland: Centers for Medicare & Medicaid Services; 2013.
National and Local Coverage Determinations. Acr.org. https://www.acr.org/Advocacy-and-Economics/Radiology-Economics/Medicare-Medicaid/Coverage.