Medicare Advantage Plans National and Local Coverage Determinations Form
500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM
EFFECTIVE DATE: 12|17|2019 POLICY LAST REVIEWED: 11|19|2025
OVERVIEW Coverage determinations, including medical necessity, for Medicare Advantage Plan members are made in accordance with the applicable Centers for Medicare and Medicaid Services (CMS) payment policies, National Coverage Determinations (NCD) and Local Coverage Determinations (LCD).
Blue Cross & Blue Shield of Rhode Island (BCBSRI) must follow CMS guidelines, such as national coverage determinations or local coverage determinations for all Medicare Advantage Plan policies. Therefore, Medicare Advantage Plan policies may differ from Commercial Products plan policies. In some instances, Blue Cross & Blue Shield of Rhode Island benefits for Medicare Advantage Plans may be greater than what is allowed by CMS.
MEDICAL CRITERIA Not applicable
PRIOR AUTHORIZATION
Not applicable
POLICY STATEMENT Blue Cross & Blue Shield of Rhode Island makes coverage determinations in accordance with all current CMS National Coverage Determinations and Local Coverage Determinations.
Blue Cross & Blue Shield of Rhode Island applies the following defined hierarchy for policy determinations.
National Coverage Determinations are the primary source for policy determinations.
If there is no NCD, and there is one Medicare Administrative Contractor (MAC) which has an LCD and exclusive jurisdiction for an item or service, BCBSRI utilizes that particular LCD. This applies when there is only one provider/laboratory for the particular item or service, so the MAC for that region processes all claims for that item or service.
Jurisdiction for proprietary laboratory services furnished by an independent laboratory normally lies
with the MAC serving the area where the laboratory is located. However, there are some situations
where a regional or national lab vendor has locations in various states. In these instances, the LCD
from the jurisdiction where the lab is headquartered would be used.
If there is no NCD and no exclusive jurisdiction situation, BCBSRI utilizes the LCDs under the direction of the local Medicare Administrative Contractor (MAC) for Rhode Island’s jurisdiction.
If there is no NCD, no exclusive jurisdiction situation, and no LCD from the Rhode Island regional MAC, BCBSRI will apply policy determinations developed using peer-reviewed scientific evidence.
When a service requires prior authorization, and CMS documented criteria in an NCD or LCD is being followed, a BCBSRI policy may not be produced. See the Related Policies Section for further information.
Medical Coverage Policy | Medicare Advantage Plans National and Local Coverage Determinations d
500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM
When a service follows the medical necessity and diagnosis edits identified in an NCD or LCD, a BCBSRI policy may not be produced.
CMS payment policies, NCDs, and LCDs are subject to change. BCBSRI applies the most current versions of the payment policies, NCDs, and LCDs in making coverage determinations. Providers are responsible for reviewing CMS payment policies and other available CMS guidance.
COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable benefits/coverage.
BACKGROUND Blue Cross & Blue Shield of Rhode Island’s internally developed policies are based on published guideline statements, physician specialty society recommendations, and other forms of credible scientific evidence published in peer reviewed medical literature, suggesting a causative relationship between the health service and improved patient outcomes.
Definitions
Local Coverage Determinations: A Local Coverage Determination is a decision by a Medicare Administrative Contractor whether to cover a particular service on a MAC-wide basis. Codes describing what is covered and what is not covered can be part of the LCD. This includes, for example, lists of CPTs or HCPCS codes that spell out which services the LCD applies to, lists of ICD-10-CM codes for which the service is covered and even lists of ICD-10-CM codes for which the service is not considered reasonable and necessary.
Medicare Administrative Contractor (MAC): a network of private organizations contracted with CMS that carry out the administrative responsibilities of traditional Medicare (Parts A and B). The network is awarded a geographic jurisdiction to provide administrative functions for Medicare Part A and Part B beneficiaries. MACs are multi-state, regional contractors.
Rhode Island’s current MACs are:
• National Government Services (NGS) for A/B services. Rhode Island is part of Jurisdiction K for A/B services
o National Government Services: https://www.ngsmedicare.com • Noridian for durable medical equipment. Rhode Island is part of Jurisdiction A for durable medical equipment.
o Noridian Healthcare Solutions: https://med.noridianmedicare.comNational Coverage Determinations: coverage determinations made by CMS that outline the extent to which specific services, procedures, or technologies are within the scope of a Medicare benefit category: being considered "reasonable and necessary" for the diagnosis or treatment of an illness or injury, and which Medicare will cover on a national basis.
CMS NCD search: MCD Reports
The hierarchy for policy determinations is from Chapter 4 of the Medicare Managed Care Manual.
CODING Not applicable
RELATED POLICIES None
PUBLISHED
500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM
Provider Update, January 2026 Provider Update, February 2025 Provider Update, February 2024 Provider Update, October 2022 Provider Update, March 2021
REFERENCES Centers for Medicare and Medicaid Services. Medicare Managed Care Manual. Chapter 4, Sections 90.1, 90.4.1, 90.5
i
This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS
Walk through this policy with us
Review how this policy can be converted into cited criteria, prior authorization checks, and operational automation.