Helpful Resources
The absence of a local coverage determination (LCD) or Medical Policy Article does not indicate noncoverage, it means that currently, National Government Services (NGS) has not identified the service requires an associated policy. These resources are available in the absence of an LCD or Medical Policy Billing and Coding Article.
NGSMedicare Website
A procedure may have other resources on our website.
Search: Perform a search using the search box located on the top right corner of our website. Select the magnifying glass icon to open up the search box.
Type your search term in the search box and select ‘Search’ to locate information across our entire website.
Search Tips
- To search for a phrase, use quotation marks around the phrase
- Search operators such as “OR” and “AND”
- Use “OR” to search for two queries, for example:
- “eye policy limitations OR benefits” will output results for both queries
- Use “AND” to indicate must-have words return in your search, for example:
- “eye policy limitations AND benefits” will output results that contain both “limitation” and benefits” words
- Use “OR” to search for two queries, for example:
Fee Schedule Lookup
Part B: Use the fee schedule lookup tool to research a CPT/HCPCS procedure code by performing a single code search in the Medicare Physician Fee Schedule. Enter the applicable CPT or HCPCS procedure code, date of service, state and locality.
Part A/HHH/FQHC: Visit Fee Schedules and Pricers for Prospective Payment Systems and Pricers and other fee schedule search options.
We are continuously adding new educational topics to our website. Explore Medicare Topics for easy access to categorized resources:
National Coverage Determinations (NCDs)
NCDs are developed by CMS and generally outline the conditions for which an item or service is covered, or noncovered, under § 1862(a)(1) of the Social Security Act or other applicable provisions of the Act.
CMS may indicate a NCD if they find an inconsistent local coverage policy, services represent a significant medical advance and no similar service is currently covered by Medicare, service is subject of substantial controversy or a potential rapid diffusion of an overuse exists.
Select National Coverage Determinations from our Medical Policies web page for an alphabetical listing of NCDs within CMS’ Medicare Coverage Database.
Centers for Medicare & Medicaid Services (CMS) Website
The CMS website has a wealth of information for policies and guidelines.
- Internet-Only Manuals (IOMs)
- The CMS IOM program issuances, day-to-day operating instructions, policies and procedures that are based on statutes, regulations, guidelines, models and directives. They are also a good source of Medicare and Medicaid information for the general public.
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- MLN Matters® Articles
- MLN Matters® Articles focus on coverage, billing, and payment rules for specific provider types and are written in n an easy to understand format. These articles are prepared with input from clinicians, billing experts, and CMS subject matter experts and cover a variety of topics.
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- National Correct Coding Initiative (NCCI) Edits are updated quarterly and available on the CMS website. For the NCCI Policy Manual and the latest version of NCCI Edits, visit the National Correct Coding Initiative Edits web page.
- Medically Unlikely Edits (MUEs) CMS’ Medically Unlikely Edits web page.
Reasonable and Necessary
Section 1862(a) (1) (A) of the Social Security Act directs the following: “No payment may be made under Part A or Part B for any expenses incurred for items or services not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
Malformed defined: (of a person or part of the body) abnormally formed; misshapen.
In the absence of an LCD/NCD, or CMS IOM instruction, reasonable and necessary guidelines apply.
NGS will determine if an item or service is medically reasonable or necessary under the direction of Section 1862(a)(1)(A) of the Social Security Act. An item or services is considered reasonable and necessary if it’s:
- Safe and effective;
- Not experimental or investigational; and
- Appropriate, including the duration and frequency that’s considered appropriate for the item or service in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member;
- Furnished in a setting appropriate to the patient's medical needs and condition;
- Ordered and furnished by qualified personnel;
- One that meets, but does not exceed, the patient's medical need; and
- At least as beneficial as an existing and available medically appropriate alternative.
Revised 9/29/2022