Breast Reconstruction Following Mastectomy

Introduction

This page displays your requested National Coverage Determination (NCD). The document is broken into multiple sections. You can use the Contents side panel to help navigate the various sections.

National Coverage Determinations (NCDs) are national policy granting, limiting or excluding Medicare coverage for a specific medical item or service.

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More information

NCDs are developed and published by CMS and apply to all states. NCDs are made through an evidence-based process, with opportunities for public participation. Medicare coverage is limited to items and services that are considered "reasonable and necessary" for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare Administrative Contractors (MACs) are required to follow NCDs.

If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, an item or service may be covered at the discretion of the MAC based on a Local Coverage Determination (LCD). LCDs cannot contradict NCDs, but exist to clarify an NCD or address common coverage issues.

Prior to implementation of an NCD, CMS must first issue a Manual Transmittal, CMS ruling, or Federal Register Notice giving specific directions to claims-processing contractors. That issuance, which includes an effective date and implementation date, is the NCD. If appropriate, the Agency must also change billing and claims processing systems and issue related instructions to allow for payment. The NCD will be published in the Medicare National Coverage Determinations Manual. An NCD becomes effective as of the date of the decision memorandum.