Coverage Criteria and Utilization Management

Medicare coverage is limited to clinically proven items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category).

A National Coverage Determination (NCD) is a nationwide determination policy setting forth the extent to which Medicare will cover specific services, procedures, technologies, devices, and items. NCDs are made through an evidence-based process, with opportunities for public participation. In some cases, the Centers for Medicare & Medicaid Services' (CMS) own research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC).

In the absence of a national coverage policy, an item or service may be covered based on a Local Coverage Determination (LCD) if it is specific to the geographic area where the service is being provided.

Items and services that are not determined by Medicare to be medically necessary are not covered by Medicare or Nascentia Health Plus.

Plan-specific policies and guidelines established by the health plan are considered in decisions only if CMS Coverage Policies, NCDs, LCDs, or guidance from the Medicare Benefit Policy Manual are not applicable to the service being requested. Utilization review criteria, such as InterQual or Milliman guidelines, provide evidence-based criteria for determining the medical necessity and appropriateness of services and will be referenced when making coverage determinations.

You can find all Medicare National Coverage Determination (NCD) notices and Medicare Administrative Contractor Local Coverage Determination (LCD) notices on the Medicare Coverage Database at: https://www.cms.gov/medicare-coverage-database/search.aspx

Last Updated on August 18, 2024