National coverage determinations set the floor and local determinations fill the gaps, so identical care is covered differently depending on which Medicare contractor adjudicates. A service routinely paid in one state can be denied across the border under the same program.
A practice with two locations discovers the same service is paid at one and denied at the other. Nothing about the medicine differs. The contractor does.
The two layers
National coverage determinations are decided centrally and apply everywhere. They are relatively few, and they establish a floor.
Local coverage determinations are issued by individual Medicare contractors for their own jurisdictions, covering everything national policy does not address. They set the specific criteria — indications, frequency limits, documentation requirements — for a service in that jurisdiction.
Because contractors write their own, a service with no national policy can have different criteria in different parts of the country.
What this means practically
- Policy advice does not travel. Guidance that is correct in one jurisdiction may be wrong in yours.
- Multi-state practices need per-location rules. One internal policy across locations under different contractors will be wrong somewhere.
- Appeals should cite the local determination. Arguing general medical necessity against a specific local policy is arguing past the reviewer.
Using them properly
Local coverage determinations are public, searchable, and written as criteria lists. For any service you bill in volume, reading the one that governs it is an hour that pays back repeatedly — it tells you exactly what the note must contain.
They also change. A service covered last year can have new criteria this year, and the denial that follows looks like a payer error rather than a policy update. Checking the current version when denials spike on a specific service is a fast way to find the cause.
Read the policy before you appeal
Most LCDs list covered indications, required documentation and sometimes specific diagnosis codes. An appeal that does not address those criteria is arguing past the reason for the denial.
The policy is published. Reading it converts a general medical necessity argument into a point-by-point demonstration, which is what actually overturns.
Multi-state practices need multiple answers
A group operating across contractor jurisdictions cannot have one coverage rule. The same service, the same documentation, and a different outcome depending on where it was delivered.
Map your locations to contractors once, then check policies per jurisdiction for the services that matter.
Use them proactively
LCDs describe what documentation the contractor expects. That is a specification you can write to before the claim rather than a standard you discover during an appeal.
Common questions
- What is the difference between an LCD and an NCD?
- A national coverage determination applies everywhere. A local coverage determination is issued by a Medicare contractor and applies only in its jurisdiction.
- Why is the same service covered differently by state?
- Because where no national determination exists, the local contractor decides. Different contractors reach different conclusions on the same service.
- How do I find the LCD that applies to me?
- Identify your Medicare Administrative Contractor, then look up the determination for the service in their jurisdiction. The contractor is determined by geography.
- Can I appeal a denial based on an LCD?
- You can appeal whether the policy was applied correctly to your case. Challenging the policy itself is a different and much harder route.
- Do LCDs change?
- Yes, with notice and comment periods. A service covered last year can have its criteria tightened, which is why the denial appears without anything changing in your practice.
Denials Piling Up?
We handle the revenue cycle end to end — coding by certified coders, claim submission, denial management and appeals, and A/R follow-up, with six reported numbers every month.