CMS Pub. 100-16, ch. 4, § 90.3

Medicare coverage policies specify which items and services are covered (or not covered)

under Part A or Part B of the Medicare program and under what circumstances (including

the clinical criteria under which the item or service must be covered). Medicare coverage

policies have several sources:

• NCDs made by CMS;

• Local Coverage Determinations (LCDs);

• Legislative changes in benefits applied through notice and comment rulemaking

(often codifying the changes in the Code of Federal Regulations); and

• Other coverage guidelines and instructions issued by CMS (e.g., Change requests and

Program Transmittals).

As indicated in section 10.2 above, MA plans must provide all items and services

classified as original Medicare-covered benefits. In applying this rule to NCDs, different

rules apply depending on whether the significant cost criterion, described above in

section 90.3, has been met.