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National Coverage and Medical Review Policy

The Centers for Medicare and Medicaid Services (CMS) has established National Coverage Determinations (NCD) and allows local carriers to establish Local Coverage Determinations (LCD). Certain tests are then "targeted" and subsequently require proof of medical necessity in the form of specific ICD-10-CM diagnosis code(s). CMS has authorized Medicare carriers to deny payment for laboratory services on the basis of NCD and LCD guidelines.

Please contact our Client Service Department for the latest list of "targeted" tests and frequency guidelines.

 Medicare National Coverage Determinations (NCD)

Medicare Local Coverage Determinations

Medical necessity requirements by payer

Aetna reimbursement policy

Anthem reimbursement policy

CareSource reimbursement policies

Centene product reimbursement policies

Buckeye Medicaid, Managed Health Services and Ambetter of Indiana

Cigna reimbursement policy

Medical Mutual reimbursement policies

United Health Care Community Plan clinical lab and other reimbursement policies

Medical necessity requirements following Medicare

The following Insurance plans follow Medicare (CMS) LCD/NCD guidelines. The CMS NCD/LCD resources can be used to identify testing and diagnosis that will be affected by this policy.

  • Advantra Coventry
  • Aetna Medicare
  • Anthem Medicare
  • Humana Medicare
  • Molina Medicaid
  • Molina Medicare
  • United Health Care Medicare (Secure Horizons)