Reviewing Claims in the Absence of Policies and Guidelines

3.3.3 - Reviewing Claims in the Absence of Policies and Guidelines (Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) The MACs, CERT, Recovery Auditors, and UPICs have the discretion to review claims, in the absence of polices, whether a NCD, coverage provision in an interpretive Medicare manual, or LCD exists for that service. When making individual claim determinations, they shall determine that the service in question is covered based on whether the service meets all of the conditions listed in section 3.6.2.1.