Limited coverage, LCD, NCD AND NON COVERED DENIAL

Definition of Limited Coverage

Coverage of certain procedures is limited by the diagnosis. If the diagnosis listed on the claim is not the same as one of those listed as covered for the procedure, the procedure is denied.

Limited coverage may be the result of national policy or an LCD. National Coverage Determinations (NCDs) are published on the CMS Web site at:

http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS014961

The official version of LCDs may be viewed on the TrailBlazer Web site:
http://www.trailblazerhealth.com/Tools/LCDs.aspx?DomainID=1

Expectations

Despite the fact some physicians, providers or suppliers may have a limited degree of contact with patients, they are expected to be aware of both national coverage policy and current LCD. In the absence of national coverage policy, an LCD indicates which items/services will be considered reasonable, medically necessary and appropriate. In most cases, the availability of this information indicates the physician, provider or supplier knew, or should have known, the item/service would be denied as not medically necessary.

If there is a question regarding the number of times a service has been furnished to the beneficiary within a specific period, the physician, provider or supplier should clarify this information with either the beneficiary or the physician who ordered the tests.

Reasons for Non-Coverage

Services denied by the Medicare program as not medically necessary or reasonable fall into these general categories:
• Experimental and investigational.
• Not safe and effective.
• Limited coverage based on certain criteria.
• Obsolete tests.
• Number of services exceeds the norm and no medical necessity demonstrated for the extra number of services.

Patient Responsibility

Services denied by the Medicare program as not medically necessary can be billed to the patient if the physician, provider or supplier had the patient sign a proper ABN prior to the service(s) being furnished.

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