A Local Coverage Determination is a Medicare Administrative Contractor’s written decision about whether a specific item or service is reasonable and necessary for Medicare to cover in that MAC’s jurisdiction, issued when no National Coverage Determination has already settled the question nationally.
Billers read the LCD, find no CPT, HCPCS, or ICD-10 codes sitting inside it, and assume the policy has nothing to say about their claim.
Usually the codes just moved next door into the associated Billing and Coding Article, and the claim gets denied anyway.
In this guide, we’ll go through how LCDs actually work and where billing teams lose claims to coverage rules they didn’t know applied. Let’s explore:
That makes LCD review a medical billing issue as much as a coding issue: a technically accurate code can still fail when the claim does not meet the applicable coverage policy.
- Finding the LCD that actually governs a specific claim
- Knowing exactly who gets to challenge an LCD in the first place
- Telling LCD reconsideration and claim appeal apart before filing the wrong one
- How LCD status (proposed, active, future effective, retired) affects claims in progress
TLDR: Local coverage determination
- A Local Coverage Determination is a MAC’s local ruling on whether a service meets Medicare’s reasonable and necessary standard under Section 1862(a)(1)(A), used only when no NCD already decides the question.
- Most LCDs no longer list CPT, HCPCS, or ICD-10 codes directly. Those codes usually live in the paired Billing and Coding Article, except for DME LCDs, which can still contain them.
- The Medicare Coverage Database lets a biller search by CPT or HCPCS code, filter by MAC jurisdiction and status, then open both the LCD and its Article before the claim goes out.
- LCD reconsideration asks a MAC to change the policy itself. A claim appeal challenges one specific payment decision. Filing the wrong one costs weeks, not minutes.
- LCD status (proposed, active, future effective, retired) changes what a policy means for a claim in progress, and a retired LCD can still govern an old date of service.
- Only a Medicare beneficiary can formally challenge an LCD’s validity through the appeals process. Providers request reconsideration. Manufacturers can submit new supporting evidence.
- Medicare Advantage plans generally must cover what Original Medicare covers, but they can layer their own utilization management on top of the underlying LCD.
What is a Local Coverage Determination?
A Local Coverage Determination is a written coverage policy issued by a Medicare Administrative Contractor deciding whether a specific item or service is reasonable and necessary under Medicare Part A or Part B, within that MAC’s jurisdiction only.
It exists to fill the gap left when no National Coverage Determination already answers the same coverage question at the national level.
Two statutory sections do the heavy lifting.
- Section 1869(f)(2)(B) of the Social Security Act is where “Local Coverage Determination” gets its legal definition
- Section 1862(a)(1)(A) is where the reasonable and necessary standard that every LCD applies actually comes from
Medicare will not pay for a service just because it exists.
It pays when a MAC (or CMS at the national level) has decided the service is reasonable and necessary for the diagnosis or treatment of the beneficiary’s condition.
An LCD is simply that decision written down for one jurisdiction.
For example, Noridian Healthcare Solutions maintains an LCD for continuous glucose monitors that spells out which diagnosis categories, monitoring frequency, and documentation elements support coverage in its jurisdiction.
A practice in a different MAC’s territory billing the identical CPT code is governed by a different LCD — potentially with different coverage criteria attached to the same service.
The same CPT code can be covered in one MAC jurisdiction and denied in another, so checking “the LCD” only matters once a biller knows which LCD, issued by which MAC, applies to that exact claim.
How do LCDs, NCDs, and Billing and Coding Articles relate?
An NCD is a national Medicare coverage rule issued directly by CMS, applying in every jurisdiction without exception.
An LCD is a MAC’s local rule, filling a gap where no NCD exists or adding detail a broader NCD does not specify.
A Billing and Coding Article is the companion document that now holds most of the CPT codes, HCPCS, and ICD-10-CM code lists once found inside the LCD itself.
| Document | Issued by | Scope | Typically contains codes | Where to check |
| NCD | CMS | National (all MACs) | Sometimes | Medicare Coverage Database |
| LCD | MAC | One MAC jurisdiction | Rarely (since 2019 reform) | Medicare Coverage Database |
| Billing and Coding Article | MAC | Paired with a specific LCD | Yes (CPT, HCPCS, ICD-10) | Medicare Coverage Database |
Before 2019, LCDs contained code lists directly. CMS then separated coverage criteria (which stayed in the LCD) from billing codes (which moved to the paired Article).
Billers who search only the LCD text and find no codes assume the policy is code-neutral. The codes are in the Article sitting right next to it, and the claim denies because nobody opened the second document.
DME LCDs are the exception — they can still contain codes directly. For every other LCD, check the paired Article.
How do you find the LCD that governs your claim?
The Medicare Coverage Database is the lookup tool. It lets a biller search by CPT or HCPCS code, filter by MAC jurisdiction and LCD status, and open both the LCD and its paired Billing and Coding Article.
Search steps
- Enter the CPT or HCPCS code for the service
- Filter by your MAC’s jurisdiction
- Filter by status (active LCDs govern current claims)
- Open the LCD for coverage criteria
- Open the paired Billing and Coding Article for the code list and modifier requirements
Reading the LCD
Every LCD contains a standard set of fields.
- Utilization guidelines
- Documentation requirements
- Effective and retirement dates
- Contractor name and jurisdiction
- Coverage indications and limitations
The coverage indications section is where medical necessity criteria live — the specific clinical conditions, documentation elements, and utilization thresholds the MAC requires for coverage.
If your documentation doesn’t satisfy those criteria, the claim denies regardless of code accuracy.
When expected Medicare noncoverage could shift financial responsibility to the beneficiary, practices may also need to evaluate whether an Advance Beneficiary Notice (ABN) applies.
What does LCD status mean for your claim?
LCD status determines whether a policy applies to a claim on a given date of service.
| Status | What it means |
| Proposed | Draft policy open for comment — not yet enforceable |
| Active | Currently in effect and governing claims in the MAC’s jurisdiction |
| Future effective | Finalized but not yet active — effective date published |
| Retired | No longer in effect for new dates of service |
Retired LCDs still apply to old dates of service
A retired LCD can still govern a claim with a date of service that falls within the LCD’s active period.
If an LCD was active January 1-June 30 and retired July 1, a claim for a May 15 date of service is still governed by the retired LCD’s criteria.
Billing teams running retrospective claims or appeals need to check the LCD that was active on the date of service, not the one currently in effect.
What is the difference between LCD reconsideration and a claim appeal?
LCD reconsideration asks a MAC to change the policy itself.
A claim appeal challenges one specific payment decision. Filing the wrong one costs weeks, not minutes — and the process, the audience, and the outcome are completely different.
| Feature | LCD reconsideration | Claim appeal |
| What it challenges | The LCD policy as written | A specific claim denial |
| Who can request | Providers, manufacturers (with new evidence) | Medicare beneficiaries (providers can represent) |
| Filed with | The MAC that issued the LCD | The MAC’s appeals department, then ALJ, etc. |
| Outcome if successful | MAC revises or retires the LCD | Specific claim is overturned |
| Timeline | Months (MAC review cycle) | Weeks to months (five-level appeal process) |
So who can challenge an LCD?
- A provider can request reconsideration from the MAC
- A manufacturer can submit new clinical evidence supporting coverage
- A Medicare beneficiary can formally challenge an LCD’s validity through the Medicare appeals process
Providers cannot formally challenge the LCD itself through the appeals process — that right belongs to the beneficiary.
What providers can do is request reconsideration, which asks the MAC to revisit the policy based on new evidence or a different interpretation of existing evidence.
How do Medicare Advantage plans interact with LCDs?
Medicare Advantage plans generally must cover what Original Medicare covers, including services governed by LCDs.
However, MA plans can layer their own utilization management — prior authorization requirements, step therapy, quantity limits — on top of the underlying LCD criteria.
A service that’s covered under an LCD in Original Medicare may still require PA under the patient’s MA plan. The LCD governs whether the service is covered. The MA plan may govern how coverage is accessed.
What are the most common LCD-related billing mistakes?
- Using a retired LCD’s criteria for a current-date claim
- Checking only the LCD and not the paired Billing and Coding Article
- Ignoring proposed LCDs that will take effect before the planned date of service
- Billing a service without confirming it meets the LCD’s specific documentation requirements
- Filing a claim appeal when the real issue is the LCD policy itself (or vice versa)
- Assuming one MAC’s LCD applies to a different MAC’s jurisdiction
When one of these mistakes produces an unpaid claim, denial management starts with identifying whether the problem is claim-specific or rooted in the underlying coverage policy.
Your claim should never deny because nobody checked the LCD
LCD-related denials are preventable with one step — checking the Medicare Coverage Database before the claim ships, opening both the LCD and the paired Article, and confirming the documentation meets the MAC’s specific criteria.
Effective claim scrubbing should include that coverage-policy check alongside code, modifier, and documentation validation.
That pre-submission review increases the likelihood that the practice sends a clean claim instead of discovering the coverage problem after adjudication.
MedHeave‘s medical billing services check LCD criteria and Billing and Coding Articles as part of pre-submission review, so coverage gaps surface before the claim reaches the MAC.
- Denials routed to LCD reconsideration or claim appeal
- Proposed and future-effective LCD changes monitored
- LCD and Billing & Coding Article review by MAC jurisdiction
- Documentation checked against LCD coverage criteria
- Performance-based pricing (4-7%) with no lock-in
Contact us if LCD-related denials are showing up in your claims and your pre-submission process needs a coverage review.
Frequently asked questions
Here are some commonly asked questions about local coverage determination:
A Local Coverage Determination is a Medicare Administrative Contractor’s written policy deciding whether a specific item or service meets Medicare’s reasonable and necessary standard within that MAC’s jurisdiction. LCDs apply when no National Coverage Determination already addresses the same coverage question nationally. Each MAC issues its own LCDs, so the same CPT code can be governed by different criteria depending on which MAC processes the claim. LCDs are found in the Medicare Coverage Database alongside their paired Billing and Coding Articles.
Since a 2019 CMS reform, most LCDs no longer contain CPT, HCPCS, or ICD-10 code lists directly. Those codes moved to the paired Billing and Coding Article — a separate document linked to the LCD in the Medicare Coverage Database. DME LCDs are the exception and may still contain codes directly. Checking only the LCD text and not the paired Article is one of the most common reasons billing teams miss coverage requirements that lead to denials.
An NCD is issued by CMS and applies nationally across all MAC jurisdictions. An LCD is issued by a single MAC and applies only within that MAC’s territory. NCDs take precedence — a MAC cannot issue an LCD that contradicts an NCD. LCDs fill gaps where no NCD exists or add local detail to a broader national policy. Both use the same reasonable and necessary standard from Section 1862(a)(1)(A), but their geographic scope and issuing authority differ.
A provider can request LCD reconsideration from the MAC, asking it to revisit the policy based on new evidence or a different interpretation. However, only a Medicare beneficiary can formally challenge an LCD’s validity through the Medicare appeals process. Providers can represent beneficiaries in appeals, but the challenge right belongs to the patient. Filing a claim appeal when the actual issue is the LCD policy itself wastes time and reaches the wrong decision-maker.
Yes, if the date of service falls within the LCD’s active period. A retired LCD governs claims for dates of service that occurred while it was in effect, even if the LCD has since been replaced or withdrawn. Billing teams working retrospective claims or appeals must check the LCD that was active on the specific date of service rather than the currently active version. The Medicare Coverage Database shows historical LCD versions with their effective and retirement dates.
