LCD & NCD Reference — Specialty Coverage Policies
How LCDs Work (Quick Orientation)
A Local Coverage Determination (LCD) is your MAC’s own determination of whether a service is reasonable and necessary, filling gaps where no National Coverage Determination (NCD) exists.¹ LCDs list covered CPT/HCPCS codes and the ICD-10-CM codes that support medical necessity — but a code appearing in the LCD’s code list does not automatically mean it’s tied to coverage criteria; check the “Coding Guidelines” under LCD Attachments to confirm.² This note pairs with Medical Necessity for Inpatient and Audit Triggers for Inpatient — LCD non-compliance is a direct audit trigger, not just a payment issue.
Tip
Medicare Contractors for Wisconsin:
- DME MAC - Jurisdiction B which is handled by CGS Administrators.
- A/B MAC (Part A and B) - Traditional Part A and B claims processing for Wisconsin is handled by other designated regional contractors (such as National Government Services, NGS or Wisconsin Physicians Service, WPS), depending on the specific provider type.
Ophthalmology
Cataract Surgery in Adults (LCD L34203 / Article A57195)
Confirmed current on both Noridian JE and JF Active LCD lists as of 8/13/2026.³ Covers CPT 66830, 66840, 66850, 66852, 66920, 66940, 66982, 66983, 66984, 66987, 66988 — the baseline policy that MIGS and other adjunct procedures reference back to.
Micro-Invasive Glaucoma Surgery / MIGS (LCD L38299 / Article A57863)
Confirmed current on both Noridian JE and JF Active LCD lists as of 8/13/2026.⁴ Covers CPT 66183, 66989, 66991, 0253T, 0449T, 0450T, 0474T, 0671T.
- Covered codes (limited coverage): 66989, 66991 — insertion of glaucoma drainage device(s) into the trabecular meshwork (e.g., iStent), when performed in conjunction with cataract surgery on the same date of service.
- Unit limitation: Only 1 unit per eye, per date of service for 66989/66991 — even if the insertion tool deploys more than one device (e.g., iStent inject) in a single pass, because once the tool is deployed there’s negligible additional work to justify multiple units.⁵
- Same 1-unit-per-eye logic applies to CPT 0449T/0671T for similar trabecular meshwork drainage device insertion; do not report 0671T alongside 66989 or 66991 — they’re mutually exclusive on the same claim.⁶
- Cross-reference: see L34203 Cataract Surgery in Adults LCD for the underlying cataract-surgery coverage indications that MIGS billing depends on.⁷
- Documentation standard: the submitted medical record must support the specific ICD-10-CM code(s) billed, and the CPT/HCPCS code must accurately describe the service performed — generic glaucoma documentation without procedure-specific detail is a denial risk.⁸
Glaucoma Screening (Preventive Benefit — Not the Surgical LCD)
Covered once every 12 months for high-risk beneficiaries only: family history of glaucoma, African American age 50+, Hispanic American age 65+, or diabetic.⁹ Must include a dilated eye exam with IOP measurement plus either direct ophthalmoscopy or slit-lamp biomicroscopy.¹⁰ Don’t confuse this preventive benefit with diagnostic/surgical glaucoma coding — different coverage pathway entirely.
Cataract Diagnostic Testing Limitation
Medicare covers one comprehensive eye exam (or a brief/intermediate exam combination not exceeding a comprehensive-exam charge) for cataract diagnosis — additional diagnostic tests are denied as not reasonable and necessary unless supported by an additional diagnosis with medical necessity fully documented in the record.¹¹
Urology
Urodynamics (CMS Coverage Article A56802 — No Attached Noridian LCD)
Verified: Urodynamics does not appear on either the Noridian JE or JF Active LCD list (checked 8/16/2026) — coverage runs off the national coverage article A56802 directly, with no jurisdiction-specific LCD layered on top.¹² This means you won’t find a Noridian LCD number to cite for urodynamics; A56802 is the correct and complete citation. Governs coverage and coding logic for the urodynamics test battery:
- EMG studies (51784/51785): electromyography of anal/urethral sphincter — 51784 for standard technique, 51785 when needle EMG placement is required.¹³
- 51797 (add-on, intra-abdominal voiding pressure): can only be reported in conjunction with 51728 or 51729 — never standalone, and never with modifier -51 since it’s an add-on code with fees that are not reduced.¹⁴
- Voiding Pressure Studies (51728/51729): measure detrusor contractility and detect outlet obstruction when the patient is able to void; simultaneous detrusor + urethral pressure measurement is especially useful for diagnosing urodynamic obstruction.¹⁵
- Urethral pressure studies: reserved for cases where other tests are inconclusive — used to rule out severe urethral incompetence, not a first-line test.¹⁶
- Stimulus Evoked Response (51792): limited practical application — mainly used to evaluate suspected cauda equina syndrome.¹⁷
Split Billing / Physician Availability
“Incident to” rules require the physician be immediately available (in the office suite) when urodynamics is performed by a nurse or technician — this is a documentation and compliance point auditors check, not just a coding one.¹⁸
Otolaryngology (ENT)
Balloon Dilation of Sinuses or Eustachian Tubes (No Attached Noridian LCD)
Verified: balloon/eustachian tube dilation does not appear on either the Noridian JE or JF Active LCD list (checked 8/16/2026), which confirms what the source material stated — Medicare has no national coverage manual entry or NCD for this, and no formal Noridian LCD/LCA exists either.¹⁹ Coverage determinations run off Medicare Advantage internal criteria and commercial/payer-specific medical policy rather than a citable Noridian LCD number — if you need a policy citation for this procedure, you’ll be citing the relevant MA plan’s or commercial payer’s medical policy document, not a Noridian LCD.²⁰
- Key bundling-coverage interaction that still applies: balloon sinuplasty performed in conjunction with FESS or other more extensive sinus surgery of the same sinus is considered an integral part of that procedure and is not separately reimbursable — this is a coverage-policy statement referenced in payer medical policy, not just an NCCI edit, so it reinforces the PTP bundling rule you already have documented for 31295–31298.²¹
Chronic Rhinosinusitis Documentation Threshold (General Payer Pattern)
While this specific threshold comes from commercial/Medicare Advantage medical policy rather than the Noridian LCD directly, it reflects the clinical documentation bar reviewers commonly apply: chronic sinusitis persisting 12 weeks or longer with negative impact on quality of life, plus CT and/or nasal endoscopic evidence of persistent sinus pathology.²¹ Worth having your op notes/H&Ps reflect this timeframe explicitly when balloon dilation or FESS is billed, since it’s the documentation pattern reviewers are trained to look for even where the payer-specific policy language differs slightly.
Cross-Specialty Takeaway
The recurring theme across all three specialties: LCD coverage and NCCI bundling are not the same gate. A code can pass NCCI (no PTP edit) and still be denied on medical necessity if the ICD-10-CM doesn’t match the LCD’s covered diagnosis list, or vice versa. Check both — this is exactly the kind of two-layer denial that shows up as a preventable audit finding.
Maintenance Note
LCDs and coverage articles get revised — Noridian’s Active LCD list flags current effective/revision dates. When updating this note, log the LCD ID and revision date in a last_verified YAML field the way you did for NCCI PTP Edits — Specialty Reference.