The Same Service, Covered Here and Denied Next Door

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.