Knowledge Base Article

As of the writing of this article, there are 344 Medicare National Coverage Determinations (NCDs), 1,207 Local Coverage Determinations (LCDs) and 1,197 local Articles. From the Medicare Coverage Determination Process webpage, “Medicare coverage is limited to 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). National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation. In some cases, 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 at the discretion of the Medicare contractors based on a local coverage determination (LCD).” LCDs may also be developed when there is a need to further define an NCD. LCDs only contain reasonable and necessary language. Other information related to an item or service that does not deal with the medical necessity of the item/service is communicated through an article. At the end of an LCD that has an associated article, there is a link to the related article and vice versa.

When I first became aware of LCDs in my Compliance career, they were called LMRPs (Local Medical Review Policies). The main concept of LMRPs at the time was of a list of covered diagnoses (defined by, at that time, ICD-9 diagnosis codes). If an item, test, or service that had an LMRP was performed and one of the “covered” diagnosis codes was not on the claim, the line item for the item, test, or service was denied. LCDs still have lists of diagnosis codes (now ICD-10 codes) that support the medical necessity of the services. However, today’s policies go beyond the diagnosis codes and describe the indications and limitations for coverage. And although some LCDs are retired and others created, it seems that LCDs as a whole are addressing a wider range of services than ever before.

For example, National Government Services (NGS), the Medicare Administrative Contractor (MAC) for Jurisdictions J6 and JK, retired their existing policy for Nerve Blocks for Peripheral Neuropathy (L35029) and added a new policy for Peripheral Nerve Blocks (L36850). The older policy only addressed the limitation that nerve blocks for multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases were not considered medically necessary and therefore not covered.

The new policy defines coverage for all possible uses of nerve blocks. This includes a list of seven indications that are reasonable and necessary for coverage and a long discussion of limitations (this includes the original limitation concerning neuropathies). Covered conditions for peripheral nerve blocks include the following. These are shortened descriptions, so please see the policy for complete descriptions.

• classic mononeuritis where neuro-diagnostic studies have failed to provide a structural explanation
• complex regional pain syndrome from peripheral nerve injuries/entrapment or other extremity trauma
• diagnostically for cases in which the clinical picture is unclear
• occipital neuralgia
• suspected entrapment of the suprascapular nerve
• blocked trigeminal nerve
• preemptive analgesia for post-surgical pain control

The limitations discuss frequency, total number of injections, and injections of multiple sites among other issues.

The caution to providers is to no longer rely simply on the presence or absence of a particular diagnosis code to determine coverage of a service. Yes, the diagnosis (and corresponding code) must be present, but coverage requirements go way beyond that. The patient’s condition must meet the indications for a particular service, there must be no limitations to coverage, and the documentation in the patient’s medical record must support the required indications. If not, the service is likely to be denied should a Medicare contractor perform a medical review.

Determining if services provided to Medicare patients meet all the indications of a coverage policy is a lot harder than simply looking for a diagnosis code, both for Medicare and for the provider. This requires a complex medical review by Medicare and internal evaluation of processes and documentation by the provider. It definitely goes beyond the diagnosis code list.