Hey there, We’re Shivang & Tania. Each week, we write in plain English (and some sass) about how health insurance works, why claims get denied, and how patients and healthcare teams can get paid or reimbursed. If you’re new here, we recommend you start with Health insurance 101 (and why your checkup costs $1,000s)

Eleanor’s mother had breast cancer. During an outpatient visit, Dr. Singh, Eleanor’s physician, recommends a hereditary-cancer genetic panel: a blood test that looks for inherited variants associated with cancer risk.

Eleanor asks the only question she cares about: “Will Medicare cover and pay for this test?”

Otis, the claims expert, does not answer right away.

“That’s not one question,” he says. “It’s at least nine, and they don’t all get answered by the same person or document.”

Otis places nine empty puzzle pieces on the table:

Those nine pieces, not any one document, determine the answer.

A published code and price may look like proof Medicare will pay, but neither one establishes clear coverage.

First piece: which healthcare program are we dealing with?

A senior bloodhound in a navy blazer steps in. This is Mabel, a CMS official who explains the federal Medicare framework.

“I’m not your insurance plan,” she tells Eleanor. “CMS is the Centers for Medicare & Medicaid Services, a federal agency within the Department of Health and Human Services. CMS administers Medicare, works with states to oversee Medicaid, and carries out its work through contractors, states, and Medicare-approved private plans.”

CMS says its programs provide health coverage to more than 160 million people through Medicare, Medicaid, CHIP, and the Health Insurance Marketplace. But CMS headquarters does not personally process most individual claims. [1]

Medicare is primarily health insurance for people 65 or older. Some people qualify earlier because of a disability, ALS, or end-stage renal disease. Eleanor qualifies based on age. [17]

“Wait,” Eleanor says. “What are Part A and Part B?”

Mabel adds two cards to the table:

The letters describe different Medicare benefits, not different insurance companies. Part A can include hospital laboratory services when Eleanor is formally admitted as an inpatient. But this genetic panel is being ordered during an outpatient doctor visit, so the relevant benefit path is generally Part B. That identifies the benefit branch; it does not answer whether this particular test and use meet Medicare’s coverage requirements. [4][5]

For orientation, Part C is Medicare Advantage, the private-plan alternative for receiving Part A and Part B benefits, and Part D is prescription-drug coverage. We will not go deeper into Part D because Eleanor’s laboratory test is not a pharmacy-benefit question.

Eleanor has Original Medicare, Parts A and B. Because Dr. Singh is ordering an outpatient laboratory test, the group follows the Part B path. That is why the rest of this issue focuses on the NCDs, LCDs, MAC jurisdiction, and billing guidance relevant to Original Medicare.

Otis, the claims expert, takes over and turns the nine pieces face up.

“People treat these as different words for the same thing,” he says. “They are not.”

A test may be covered in defined circumstances and still not be payable for Eleanor. Her facts, documentation, code, jurisdiction, and date must match the applicable requirements.

One piece sits underneath all five. Congress created Medicare’s legal authority. An item or service must fit within a Medicare benefit category, must not be excluded by law, and generally must be reasonable and necessary for diagnosing or treating illness or injury—or improving the functioning of a malformed body member. [6]

FDA authorization answers a different legal question. It does not automatically create Medicare coverage or payment.

Mabel, our CMS guide, picks up the national-policy piece: a National Coverage Determination, or NCD.

CMS begins a formal National Coverage Analysis, reviews the evidence, and may use an external Technology Assessment or seek advice from MEDCAC (Medicare Evidence Development & Coverage Advisory Committee), its evidence advisory committee. CMS then posts a proposed decision for public comment and later posts a final decision memorandum explaining its conclusion.

For the standard statutory timeline, CMS generally posts the proposed decision within six months after opening the NCA. When the analysis includes an external Technology Assessment or a MEDCAC meeting, that period is generally nine months. The proposed decision receives a 30-day public-comment period, and CMS issues the final decision no later than 60 days after comments close. The overall process generally takes nine to twelve months. [7]

“An NCD answers a national Medicare coverage question,” Mabel says. “MACs must follow it. But it does not, by itself, assign a billing code or determine the payment amount.”

The final decision memorandum makes the NCD effective; manual changes and claims-system instructions may follow to implement it operationally.

A test may not have a test-specific NCD and still fall under a broader national policy. That matters in genetic testing: CMS’s NCD 90.2 governs certain next-generation sequencing tests for cancer. Never stop the search just because the product name does not appear in an NCD title.

Mabel introduces the next piece.

“A Medicare Administrative Contractor, or MAC, is a private company contracted by CMS to administer specified Original Medicare responsibilities within an assigned jurisdiction.”

A basset hound in a tan blazer welcomes the group to a regional MAC office. He is the local-policy guide for this issue; readers do not need to remember him from anywhere else. CMS currently lists 12 A/B MACs and four DME MACs. A/B MACs process Part A and Part B fee-for-service claims within defined jurisdictions; DME MACs handle durable medical equipment claims. [8]

One more distinction comes up constantly in molecular diagnostics: MolDX is not a MAC. It is a molecular diagnostic services program administered by Palmetto GBA and adopted by participating MACs. Palmetto administers the program in Jurisdictions M and J; other participating jurisdictions are administered by their respective MACs. [9]

For this example, Eleanor’s test is billed by a laboratory located in South Carolina. South Carolina is part of Palmetto GBA’s Jurisdiction M for Medicare Part A and Part B claims, together with North Carolina, Virginia, and West Virginia. That is why Jurisdiction M, not a different MAC jurisdiction, is the relevant local layer in Eleanor’s coverage puzzle. The applicable MAC can depend on the service, claim type, and billing provider or laboratory location, so teams should verify the correct jurisdiction for each case.

The MAC representative picks up the local-policy piece: a Local Coverage Determination, or LCD.

“An LCD is a MAC’s determination, within its jurisdiction, about whether a particular item or service is reasonable and necessary under Medicare’s applicable standard.” [10]

An LCD applies only within the contracts and jurisdiction identified in the document. Another MAC may have a different local policy when no controlling national rule resolves the question.

For new or revised LCDs that require the full comment-and-notice process, the MAC generally provides at least a 45-day public-comment period and at least a 45-day notice period before the final LCD becomes effective. Administrative revisions do not necessarily repeat that full process. [11]

An LCD is often linked to a separate Billing and Coding Article. For most A/B MAC policies, codes and claim-submission guidance are maintained in the related article rather than the LCD itself. The article supports the policy; it is not the LCD.

If there is no applicable NCD or LCD, that is not an automatic yes or no. The MAC may adjudicate the claim under other applicable Medicare authorities, instructions, evidence, and patient-specific facts. Silence is not a coverage determination.

Otis sorts the paperwork into five piles:

“A Billing and Coding Article is not an LCD,” Otis says. “And a fee-schedule amount does not establish coverage.”

The dates also matter. A document may have a publication date, effective date, implementation date, and retirement date. Those dates may differ. The policy version governing Eleanor’s claim is the version applicable to her date of service, not automatically the version visible today.

Using the wrong version can produce the wrong coverage analysis or weaken a denial review or appeal.

To answer Eleanor’s question, the group needs:

No single character owns all of that information. Eleanor brings her coverage and clinical history. Dr. Singh brings the order and medical record. Mabel explains the national framework. The MAC representative identifies the local rules. Otis connects the operational pieces.

That is the real shape of “Will Medicare cover this?” once we stop treating it as one question.

The Medicare Coverage Database is the primary search tool for NCDs, LCDs, and related documents. MAC websites provide contractor-specific education, meetings, and notices. CMS publishes Change Requests and Transmittals separately, while MLN Matters explains many changes for providers. The weekly MLN Connects newsletter summarizes national fee-for-service news, billing and coding updates, and educational resources.

Every character now adds the piece only they can supply:

So, is Eleanor’s test covered?

No, not based on the facts in this example.

Eleanor is unaffected: she has never received a cancer diagnosis. She is seeking hereditary-cancer testing because her mother had breast cancer. The applicable MolDX policy requires all three patient conditions: a cancer diagnosis, a clinical indication for germline testing, and a hereditary-cancer risk factor. Eleanor may have a risk factor, but she does not have the required cancer diagnosis. The puzzle is incomplete. [12]

That answer is the point of the puzzle. Dr. Singh may have a clinically reasonable reason to recommend the test. The test may have a billing code and a published price. The documentation may be complete. But none of those pieces can create coverage when Eleanor does not meet the governing policy’s conditions.

Coverage defines whether and when the door can open. Coding and documentation help a payable claim pass through it. Payment rules set the amount. Eleanor’s individual facts determine whether the coverage conditions are met.

Knowing how coverage works is useful. Building the answer into the workflow before the service is performed is where the value appears.

Choose one high-denial service and create a one-page coverage matrix before the next claim goes out. Include:

Then compare that matrix with the order, medical record, and claim. If one element is missing, route the case for clarification before testing or billing. Do not use the checklist only after a denial.

When a denial does occur, classify the failure before appealing it: coverage, coding, documentation, jurisdiction, policy version, payment, or claim processing. The appeal should address the actual failure instead of sending the same records again and hoping for a different result.

IIf you want help managing some of these moving pieces in one place, check out converus.ai. Converus AI brings payer policies, billing guidance, effective dates, and case-specific requirements into one traceable workflow, helping reimbursement teams evaluate cases before submission.

Do not stop at FDA authorization or the existence of a code. Build a payer pathway for the technology:

The useful output is not a list of links. It is a gap map: what is already supported, what remains uncertain, which decision-maker controls each issue, and what evidence or operational change could close the gap.

Before the test or service, ask:

For Original Medicare, if the provider believes Medicare may not cover the service, ask whether you should receive an Advance Beneficiary Notice of Noncoverage, or ABN, before the service. An ABN is a notice, not a coverage decision or a promise that Medicare will deny, but it should explain why payment may be denied and the estimated cost so you can make an informed choice. [16]

Keep the order, policy information, ABN if one is issued, claim, Medicare Summary Notice, and denial letter together. Those documents are much more useful in an appeal than trying to reconstruct the case months later.

The deeper operational lesson is that the service name and billing code are never enough on their own. The same test can produce a different coverage answer when the program, jurisdiction, controlling policy, policy version, or patient facts change. The useful work product is therefore not a generic checklist: it is a dated, case-specific decision record showing which rule controlled, which facts were tested against it, where uncertainty remains, and who owns the next decision.

That's it for this issue. Hit reply. I read everything.

Sources

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