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Overview
Neither federal nor private payers will pay for all available therapies and services. Instead each payer has set up its own complex system of rules that determine what services and therapies will be covered when.
Medicare Coverage Policies
Medicare Coverage Policies
Medicare uses a variety of mechanisms to set policies for coverage of services. At the national level, the Centers for Medicare and Medicaid Services (CMS) may issue a National Coverage Determination (NCD). Medicare contractors may issue Local Coverage Determinations (LCDs) or may choose to cover services or therapies on a case-by-case basis. If an NCD or LCD does not exist, it does not simply mean that Medicare will not pay for the service.
National Coverage Determinations
CMS develops NCDs to codify Medicare coverage of services that are “reasonable and necessary.” NCDs are created using an evidence-based process, with opportunities for public comment and participation. These policies may be written in a manner that provides broad coverage, coverage with certain restrictions, or non-coverage. NCDs are listed in alphabetical order on the CMS website or can also be found, along with many other documents, in the Medicare Coverage Center.
Without an NCD, a service may be covered at the judgment of Medicare administrative contractors (MACs) through an LCD.
Local Coverage Determinations
When national coverage has not been specified in an NCD, MACs may choose to provide coverage for a service through an LCD. An LCD may be written in a manner that provides broad coverage, coverage with certain restrictions, or non-coverage. MACs develop LCDs through a process that is less formal than that used to develop an NCD. That process includes expert feedback from designated physician representatives. LCDs are listed by contractor or state on the CMS website. Individual contractor websites have additional information that includes information for providers to suggest new or revised LCDs.
Most services are not addressed in either an NCD or an LCD. These services are not precluded or qualified through policy, but may be subject to coding edits for frequency, volume, or code pairs.
Private Payer Coverage Policies
Third party insurance payers such as Aetna, Blue Cross and Blue Shield, CIGNA and UnitedHealthcare maintain individual libraries of medical coverage policies. These policies contain the payer’s coverage rationale, interpretation of current medical evidence and literature as well as billing and coding instructions. Payers often include various evaluations such as clinical practice guidelines, Medicare coverage determinations, medical assessments (from governmental agencies, other health insurers and independent non-profit organizations), and sometimes use cost-effectiveness research of similar procedures or devices.
The large national insurers, including Medicare contractors, review their medical policies annually or more frequently as the medical literature and evidence evolves. The ACC has become an excellent resource for these cardiovascular related policies through its evidence-based practice guidelines, statements, and appropriate use criteria. The College continues to provide additional clinical practice input and guideline interpretation for both Medicare and private payer coverage policies.
The best way to find a specific policy for a payer is to use an internet search engine like Google, Bing, or Yahoo. Searching with the CPT® code will help narrow your search results. For example, when searching for UnitedHealthcare’s medical policy for complete transthoracic echocardiogram (CPT 93306), input “UnitedHealthcare medical policy CPT 93306” into the search box.
It is important to note some payers may have additional requirements such as prior authorization or notifications for certain services and procedures particularly diagnostic imaging tests and other cardiovascular procedures. Be sure to check with the insurer for these type requirements before rendering a service.
