coverage-check

name	coverage-check
description	Search Medicare NCDs and LCDs to determine coverage requirements
version	1.0.0
triggers	["diagnosis_and_procedure_identified","user_asks_if_covered","user_mentions_denial"]

Coverage Check Skill

This skill searches Medicare's National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) to find coverage requirements for a diagnosis + procedure combination.

Purpose

Determine:

1. Is this service covered by Medicare?
2. What documentation is required?
3. What medical necessity criteria must be met?
4. Are there any exclusions or limitations?

Process

1. Gather Required Information

Before searching, ensure you have:

• Diagnosis (ICD-10 code) — from symptom-to-diagnosis skill
• Procedure (CPT code) — from procedure-identification skill
• Location (state) — for LCD lookup

2. Search Coverage Policies

Search NCDs First (National)

searchNCD({
  procedure_code: "72148",
  diagnosis_code: "M54.5"
});

NCDs apply nationwide and take precedence.

Then Search LCDs (Regional)

searchLCD({
  procedure_code: "72148",
  diagnosis_code: "M54.5",
  state: "CA",
  contractor: "Noridian" // MAC for that region
});

LCDs vary by Medicare Administrative Contractor (MAC).

3. Check SAD List

For drugs/biologics, check the Self-Administered Drug exclusion list:

checkSAD({
  hcpcs_code: "J1234"
});

• If on SAD list → Part D (pharmacy benefit)
• If not on SAD list → Part B (medical benefit)

4. Extract Coverage Criteria

Parse the policy to find:

• Covered indications (when it's covered)
• Documentation requirements (what must be in medical record)
• Exclusions (when it's NOT covered)
• Frequency limits (how often)

5. Pull Supporting Evidence

If needed, search PubMed for clinical evidence:

searchPubMed({
  condition: "low back pain",
  intervention: "MRI",
  outcome: "diagnosis"
});

Coverage Determination Categories

Covered

Service is covered when criteria are met:

"Medicare covers lumbar MRI (72148) for low back pain (M54.5) when:
- Pain persists for 6+ weeks despite conservative treatment
- Neurological symptoms are present (weakness, numbness)
- Red flag symptoms warrant urgent imaging"

Covered with Conditions

Service is covered but has limitations:

"Medicare covers physical therapy with the following limits:
- Initial evaluation once per episode of care
- Up to 12 visits before additional documentation required
- Must show functional improvement"

Not Covered

Service is excluded:

"Medicare does not cover:
- Routine screening MRI without symptoms
- Cosmetic procedures
- Experimental treatments"

No Specific Policy

No NCD/LCD exists — coverage at contractor discretion:

"There's no specific Medicare policy for this combination.
Coverage will be determined based on general medical necessity criteria."

Documentation Requirements

Extract what the doctor must document:

Requirement Type	Example
Duration	"Symptoms present for X weeks"
Severity	"Pain level X/10 affecting daily activities"
Failed treatments	"Tried PT, NSAIDs, injections without relief"
Clinical findings	"Neurological exam showed X"
Functional impact	"Unable to perform X activities"

Common Requirements by Service

Imaging (MRI, CT)

• Duration of symptoms (usually 4-6+ weeks)
• Failed conservative treatment
• Specific clinical findings
• No contraindications

Physical Therapy

• Functional limitations
• Treatment goals
• Expected duration
• Progress documentation

DME (Equipment)

• Medical necessity statement
• Specific diagnosis
• Expected benefit
• Home use certification

Surgery

• Failed conservative treatment (usually 3-6 months)
• Imaging confirming diagnosis
• Functional limitations
• Surgical candidacy evaluation

Policy Reference Format

When citing policies, include:

NCD 220.6 - Positron Emission Tomography (PET) Scans
Effective: January 1, 2023
Contractor: National (all MACs)

LCD L35047 - MRI of the Spine
Effective: October 1, 2023
Contractor: Noridian (CA, NV, etc.)

What NOT to Do

• Never guarantee coverage: Say "typically covers" not "will cover"
• Never skip policy search: Always check current NCDs/LCDs
• Never ignore regional differences: LCDs vary by state
• Never present codes to user: Translate to plain English

Example Output

When Covered

Good news — Medicare typically covers a lumbar spine MRI for your mom's
situation. Based on her symptoms (back pain with leg involvement for 3 months),
here's what the doctor needs to document:

**Required Documentation:**
□ Pain duration: 6+ weeks (she has 3 months ✓)
□ Radiating symptoms: Pain or numbness in leg ✓
□ Failed conservative treatment: PT, medication, or home exercises
□ Neurological findings: Noted on physical exam

**Policy Reference:** LCD L35047 (Noridian)

The key thing Medicare wants to see is that she's tried simpler treatments
first. Has she done any physical therapy or taken medication for this?

When Conditionally Covered

Medicare can cover this MRI, but they'll want to see that other treatments
were tried first. This is called "conservative treatment" — things like:

- Physical therapy (usually 4-6 weeks)
- Anti-inflammatory medication
- Home exercises

Has your mom tried any of these?

When Not Covered

I looked into this carefully, and unfortunately Medicare doesn't typically
cover [service] for [reason].

Here's why: [explanation in plain English]

However, there may be some alternatives:
- [Alternative 1]
- [Alternative 2]

Would you like me to check coverage for any of these instead?

Edge Cases

No Policy Found

There's no specific Medicare policy I could find for this exact combination.
That doesn't mean it's not covered — it means the Medicare contractor will
decide based on general medical necessity.

The doctor should document:
- Why this service is needed
- What symptoms or findings support it
- What they expect it to show or accomplish

Policy Recently Changed

Note: Medicare updated their policy on this in [date]. The new requirements
include [changes]. Make sure the doctor's documentation reflects the
current criteria.

Regional Variation

Coverage for this can vary by location. In [state], the local Medicare
contractor ([MAC name]) requires:
- [Requirement 1]
- [Requirement 2]

If she's being seen in a different state, the requirements might be
slightly different.

Example Conversation

User: "Will Medicare cover her MRI?"

Assistant: [Has: M54.41 (lumbago with sciatica), 72148 (lumbar MRI), CA location]

[Searches: NCD for 72148 — none found] [Searches: LCD L35047 for 72148 + M54.41 in CA]

"I checked Medicare's coverage policies for a lumbar MRI with her diagnosis.

Good news: Medicare typically covers this when certain criteria are met.

Here's what the doctor needs to document:

1. Duration — Pain for 6+ weeks (she has 3 months ✓)
2. Radiating symptoms — Pain going into the leg ✓
3. Failed conservative treatment — Tried PT, meds, or exercises first
4. Neurological findings — Exam showing nerve involvement

The main thing I'd want to confirm: has she tried any physical therapy or medication for this? That's usually what Medicare wants to see before approving imaging."