CMS Medical Policy and Prior Auth Forms

Local Coverage Determination (LCD) and National Coverage Determination (NCD) are two types of coverage decisions made by the Centers for Medicare & Medicaid Services (CMS) in the United States regarding whether a particular medical service or item is covered (i.e., reimbursable) under Medicare.

• National Coverage Determination (NCD): These are decisions made by the Centers for Medicare & Medicaid Services (CMS) regarding whether a particular medical service, procedure, or device is considered to be reasonable and necessary, and thus covered, under Medicare. NCDs apply uniformly to all Medicare beneficiaries nationwide.


• Local Coverage Determination (LCD): These are decisions made by Medicare Administrative Contractors (MACs) about coverage of a particular service or item in their specific geographical jurisdiction. LCDs are based on the MACs' assessment of whether a service or item is reasonable and necessary within their area, taking into account local medical practices and the needs of the local beneficiary population. They can vary from one MAC jurisdiction to another.

We've parsed these documents using our platform to generate simple questionnaire's and rules which can be easily answered to determine eligibility.

These questionnaire's can be auto-populated with answers from the patient' medical record, and can be used to generate coverage recommendations.

Learn more about how to dramatically simplify coverage decisions.