LCD (Local Coverage Determination)
Local Coverage Determination
A MAC-published decision about whether a service is reasonable and necessary in its jurisdiction.
1 min read · Last reviewed May 23, 2026
At a glance
- Category
- Payer
- Acronym for
- Local Coverage Determination
- Primary sources
- 1
- Workspace handoff
- ask d3 →
Where this comes up
Front-office and billing both hit this term — eligibility before the visit, prior auth before the procedure, contract terms during fee-schedule negotiation, and credentialing whenever a new provider joins or a payer roster lapses. Misses here become denials downstream.
Full definition
What it is in practice
CMS Medicare Coverage Database lists every LCD. Each LCD specifies covered indications, limitations, ICD-10 codes that support medical necessity, and frequency limits.
How it shows up in your practice
Use the LCD as the coverage map before billing diagnostic or specialty services. Mismatched ICD-10 codes are the top driver of medical-necessity denials.
Sources
- CMS — Local Coverage Determinationshttps://www.cms.gov/medicare-coverage-database/
Check LCD details in Ask D3
Open ask d3 →Related terms
- PayerNCD (National Coverage Determination)A CMS-issued nationwide determination of whether Medicare will cover a particular service.
- CodingMedical NecessityThe standard requiring that services be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
- Denials & AppealsABN (Advance Beneficiary Notice of Non-coverage)A standardized notice (CMS-R-131) given to Medicare fee-for-service beneficiaries before furnishing a service Medicare may not cover.
- PayerMedicare Administrative Contractor (MAC)CMS-contracted regional entity that processes Medicare claims, makes coverage decisions, conducts provider education, and handles first-level appeals.
D3rx is a healthcare-billing and compliance research aid maintained by D3rx Inc. Articles are drafted by an LLM (Anthropic Claude) against primary HHS, OCR, CMS, eCFR, NIST, and state-regulator publications, and reviewed for restraint and source fidelity by the D3rx team.
Reviewer status: a named credentialed reviewer (CHC, CHPC, or healthcare attorney) is being engaged. Until that engagement is finalized, this page does not claim credentialed review.
Related across the archive
- GlossaryMedical NecessityThe standard requiring that services be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
- GlossaryNCD (National Coverage Determination)A CMS-issued nationwide determination of whether Medicare will cover a particular service.
- GlossaryMedicare Administrative Contractor (MAC)CMS-contracted regional entity that processes Medicare claims, makes coverage decisions, conducts provider education, and handles first-level appeals.
- GlossaryABN (Advance Beneficiary Notice of Non-coverage)A standardized notice (CMS-R-131) given to Medicare fee-for-service beneficiaries before furnishing a service Medicare may not cover.
- GlossaryMAC LCD ArticleA Local Coverage Article published by a MAC to provide billing, coding, or coverage clarification that does not rise to the formal LCD.
- ComplianceSMRC Audit Response: The Supplemental Medical Review Contractor WindowAn SMRC letter gives a 45-day documentation window and is shorter-fuse than RAC. Here is the response procedure and how the findings feed back to CMS and the MACs.
- RegulationMLN: Medical Necessity — Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs)Reference to Medicare's coverage determinations: NCDs are issued by CMS; LCDs are issued by MACs; both define when an item or service is reasonable and necessary.
- GlossaryCO-50 (Non-Covered Services / Not Medically Necessary)Contractual Obligation 50 — payer determines the services were not deemed medical necessity by the payer.
This glossary entry is a research aid for billing and compliance staff. It does not provide legal, medical, or financial advice and does not replace counsel. References cited link to primary sources at HHS, OCR, CMS, eCFR, NIST, and the relevant payer or industry body.