National Coverage Determination - What Triggers An NCD?

What Triggers An NCD?

NCDs can be requested by external parties who identify an item or service as a potential benefit (or to prevent potential harm) to Medicare beneficiaries. External parties who may request an NCD are medicare beneficiaries, manufacturers, providers, suppliers, medical professional associations, or health plans.

NCDs can also be internally generated by CMS under multiple circumstances.

For existing items or services

• Stakeholders have raised significant questions about health benefits of currently covered items or services
• New evidence, or re-interpretation of previously available evidence indicates that current policies may need to be changed
• Local coverage policies are inconsistent or conflicting, to the detriment of beneficiaries

For new items or services

• The technology represents a substantial clinical advance and is likely to result in significant health benefit if it is available more rapidly to patients for whom it is indicated
• More rapid access is likely to have a significant programmatic impact on Medicare policies
• Significant uncertainty exists around health benefits, patient selection, or appropriate facility and staffing requirements