LCD's and Articles, are meant (among other things) to specify the medical necessity rules instituted by the CMS (Centers for Medicare and Medicaid Services) contractors that process claims for a given locality.
Does that mean that the contractors can make up any rules they want? No, there is a set of rules that apply nationwide which the contractors are obligated to follow. These are published in documents called National Coverage Determinations (NCD's) and cannot be overridden at the whim of a CMS contractor.
The Coding Advisor consults both NCD's and the applicable LCD's for the locality in which the claim is filed, to determine if a claim is likely to be reimbursed.
If an LCD mentions a procedure and the diagnosis codes that are deemed proper to fulfill the medical necessity of performing it, then the claim will likely be reimbursed. For Medicare claims, that's an official statement.
What if the claim is for a private payer? Private payers generally are expected to follow the Medicare rules, though they are not obligated to do so. Our statement is that it is "likely" that private payers will observe the Medicare rules.
We will go deeper into the LCD rules in a future blog, so stay tuned!