Definitions Related to National Coverage Determinations (NCDs)

90.2 – Definitions Related to National Coverage Determinations (NCDs) (Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15) The contents of this section are governed by statutes and regulations including those set forth at 42 CFR §422.109. The following definitions related to national coverage determinations apply: • A National Coverage Determination (NCD) is a determination by the Secretary with respect to whether or not a particular item or service is covered under Medicare. An NCD does not include a determination of what code, if any, is assigned to a service or a determination about the payment amount for the service. HCPCS and other codes are assigned through separate guidance. • An NCD is issued under procedures that are established in the Federal Register and is published in the Medicare National Coverage Determination (NCD) manual. Each NCD will contain a specific effective date. • A legislative change in benefits is a coverage requirement adopted by the Congress and mandated by statute. The Secretary of Health and Human Services generally implements a legislative coverage change through regulation and/or sub-regulatory guidance. • The term significant cost, as it relates to a particular NCD or legislative change in benefits, means either of the following: o The average cost of furnishing a single service exceeds a cost threshold that for a calendar year is the preceding year’s dollar threshold adjusted to reflect the national per capita growth percentage described at 42 CFR §422.308(a); or o The estimated cost of Medicare services furnished as a result of a particular NCD or legislative change in benefits represents at least 0.1 percent of the national average per capita costs.