I'm Just a Determination: How Medicare Coverage Decisions Actually Get Made
It's 4:40 on a Thursday afternoon and a Wound Care Program Director is fifteen tabs deep.
It started reasonably enough. A therapy the wound center wants to offer and a question from upstairs that sounded simple when asked aloud:
Is this covered, and how do we know?
Which led to a search box on a federal website called the Medicare Coverage Database. Then a results page. Then a document. Then another…
Rule.
Article.
Rule.
Article.
An hour disappeared one click at a time, and not one of them answered the question.
And then a page loads that looks like all the others except for one thing.
Every document she'd been reading started with an L or an A followed by a string of digits.
This one has an extra letter: DL.¹
"...okay. What are you?"
Well. Since somebody finally asked.
I'm just a determination. Yes, I'm only a determination. And I'm sitting here on the Coverage Database.
Thirty-one days now.
I'm Just a Determination
The D is for draft. The L is for local.
I'm not policy yet. I'm the thing that might become one.
People find me, read me, and go implement me.
Which is a problem, because I'm not policy yet.
"So what are you about?"
Here is where most people expect me to say a product name. I'm not about a product.
I'm about when.
I say which conditions. I say how many treatments, and over what span. I say that somebody has to have tried the standard thing first and written down that it didn't work. I say who's qualified to furnish it and in what setting.
That's what I am — a few paragraphs about when something is reasonable and necessary, which is the standard the law actually asks about.²
And there's a shape to that question I have to answer, not just a vibe.
Is it safe and effective?
Is it something other than experimental or investigational?
And is it appropriate — including how long and how often?
That last one gets measured five ways.²
Furnished according to accepted standards of medical practice for the patient's condition.
Furnished in a setting appropriate to that condition.
Ordered and furnished by qualified personnel.
Care that meets, but does not exceed, the patient's medical need.
And at least as beneficial as an existing, available, medically appropriate alternative.
Every one of those is a documentation question wearing scrubs.
"And before you?"
Before me, there was no single written local answer to point at.
Every claim got worked on its own. Somebody read a patient's chart and made a call. Somebody else read a different chart and made a different one.
That isn't anybody's fault. It's just what happens when nobody's written it down yet.
I'm what written-down looks like.
Somebody Had to Write Me
"Who made you?"
A contractor.
Not a federal agency — CMS describes a Medicare Administrative Contractor (MAC) as a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B claims, or durable medical equipment claims, for Fee-For-Service beneficiaries.³
They're the primary operational contact between the program and the providers in it.³
There are twelve of them handling Part A and B, plus four handling durable medical equipment.³ Between them, they cover about 33.9 million Fee-For-Service beneficiaries, close to half the people on Medicare.³
Last fiscal year, they served more than 1.2 million providers and processed more than 1.1 billion claims, paying out roughly $459.7 billion.³
They exist because Congress said so. Section 911 of a 2003 law told CMS to retire the old Part A Fiscal Intermediaries and Part B carriers and stand up contractors in their place.³
That's the machine I'm one tiny part of.
And I want to be fair to them, because people usually aren't.
CMS lists ten things a contractor does:
Process claims
Make and account for payments
Enroll providers
Audit institutional cost reports
Handle the first stage of appeals
Answer provider questions
Teach billing requirements
Establish local coverage determinations (LCDs)
Review medical records on selected claims
Coordinate with CMS and the other contractors³
Count where I fall on that list. Eighth of ten. Writing me is one line on the job description of an organization moving a billion claims a year.
That's not a complaint. That's a workload.
But it explains something worth knowing: when an LCD is the policy behind a denial, that document was written by people with nine other jobs, published where anybody could read it.
You've been looking at it for an hour.
"Okay, but who decided you should exist at all?"
Somebody asked.
I didn't come from the top. I came from a question.
A request can come from a beneficiary living or receiving care in the jurisdiction. From a health care professional doing business there. Or from any interested party doing business there.²
A patient can start me. So can the nurse down your hall.
But asking isn't complaining. To count as a complete, formal request, it has to be in writing, and it has to do real work. The request has to:
identify the Medicare benefit category the requestor believes applies, and explain why
provide a justification supported by peer-reviewed evidence, with full copies of the published evidence attached
address relevance, usefulness, clinical health outcomes, and medical benefits
explain the design, purpose, and method of using the item or service
And one more, which is my favorite: identify the language the requestor wants in the LCD.²
You don't write in and object. You write the sentence you want me to say.
The contractor then has 60 calendar days to look at the materials and decide whether the request is complete or incomplete.² And they're careful about what that answer means — being told your request is valid doesn't convey that any determination has been made. It's an acknowledgment that a complete request arrived.²
There's a warm-up step too. The process can begin with informal meetings where interested parties discuss potential requests. Those are educational, and the manual says so flatly: they are not pre-decisional negotiations.²
You can ask questions. You can explain the evidence. You can't negotiate the determination.
That's how I got here.
Thirty-one days ago.
My Brother Handles the Codes
"Wait — where are the codes? I need a code."
Not me. Never me.
CMS pulled procedure and diagnosis codes out of documents like me entirely and moved them into a separate article.² So there's a second document, published the same day I was, saying nothing about medicine and everything about paperwork.²
He carries the procedure codes, diagnosis codes, bill types, revenue codes, and modifiers. He's also the one who says which services I apply to, and which diagnoses are covered and which aren't.¹
Articles like him carry document numbers starting with A. You scrolled past four of them.
While I'm still a draft, so is he: he starts with DA, and when I go final, he grows up into the billing and coding article.¹
He doesn't know what any of it means. He's a list.
"So which of you do I actually call?"
Ask him for a code and he'll give you one.
Ask me whether the service is covered and I'll tell you what the policy says.
Ask him whether it's covered and he'll hand you a code.
Ask me for a code and I'll point next door.
And don't ask either of us what it pays. That's not us at all. Payment is a different machine, on a different calendar, run by different people. Somebody assigns the name. Somebody else decides what the name is worth.
And neither one of those is the same as deciding whether it's covered.
That part's me.
Half the arguments in your billing office are two people asking the right question of the wrong document.
Before I Become Policy
"So how long do you get?"
Forty-five days. Minimum. Public comment, starting the day I was published.²
So: fourteen left.
"...and how many people have written?"
None yet.
"Nobody?"
Not a one.
There's usually a meeting. After I'm made public, the contractor holds an open meeting to discuss evidence and reasoning with stakeholders in the jurisdiction. Providers, physicians, vendors, manufacturers, beneficiaries, caregivers — any of them can present.² The agenda goes live at least two weeks in advance.²
But here's the thing people get wrong: all formal comments must be submitted in writing.² Showing up is good. Presenting is better. Neither is a comment. Go to the meeting, then go home and type.
There's also a committee. A Contractor Advisory Committee exists to give clinicians a formal way to see the evidence behind a document like me and to keep the contractor and the clinical community talking. It's made up of healthcare professionals, beneficiary representatives, and representatives of medical organizations.² The meetings are recorded, and open to the public to attend and observe.²
They serve voluntarily. No honorarium. They cover their own expenses.²
They came anyway.
"So the committee decides?"
No. The committee advises. The final decision rests with the contractor.²
People drive in on their own dime to look at evidence with you, and then somebody else decides. Worth knowing before you assume the room was closed to the public, or that everyone in attendance gets a vote. Neither one is true.
They Print What You Said
"If I write something, does anyone read it?"
They answer it.
When the comment period closes and the required meetings and consultation are done, the final version and a Response to Comment article publish together.² The contractor responds to all comments received during the comment period, and may group similar ones into categories.²
Then that article stays publicly available indefinitely — on the Coverage Database or in its archive.²
Your objection outlives the argument. Somebody eight years from now can read what you wrote and read what they said back.
Very few people know that. It's an extraordinary amount of institutional knowledge, and for the most part it sits there unused.
The comment period is still open for fourteen days, and the mailbox is right there.
Then I Wait, or I Don't
"Okay. So when does a determination actually take effect?"
Not the day it goes final. That's the part people miss.
Publishing a final version doesn't switch a determination on. The day it posts starts a notice period of at least forty-five calendar days. Unless that period is extended, the policy takes effect on the forty-sixth calendar day.²
There's also transparency owed before that date. At least forty-five days ahead, the contractor has to post, on its own site and the Medicare site:²
the determination in its entirety
where and when the proposal first went public
links to the proposal and the Response to Comment article
a summary of the evidence considered and its sources
the rationale for the decision²
"And if nothing happens?"
Proposals like me don't get to sit here forever. We have to be finalized or retired within 365 days.²
So one of two things happens to me. I lose the D, or I get quietly withdrawn and nobody notices I was ever out here.
Somebody Bigger Could Have Answered This
"Isn't there a national rule?"
Sometimes. National Coverage Determinations (NCDs) are national policy — CMS makes them, they are applicable in every state, and contractors have to follow them.¹
If one had spoken to this, I probably wouldn't exist. Contractors write documents like me when Medicare hasn't established national coverage for the question, or when an NCD leaves room for local coverage policy within the contractor's jurisdiction.¹
And when an NCD doesn't specifically exclude or limit something, or doesn't mention it at all, that item or service may be covered at the discretion of the contractor through a local determination. Local ones can't contradict national ones. They exist to clarify them, or to handle the coverage questions that keep coming up.¹
When the national level doesn't answer, the question doesn't disappear. It moves.
So national silence isn't a national no. It's a handoff.
Which is also why the same question can get different answers in different places without anybody having made a mistake. That's the design working, not the design failing.
If I'm Wrong
"What if you become policy and you're wrong?"
Two different doors. People regularly get them mixed up.
Reconsideration is for final, effective determinations only.
Somebody in the jurisdiction asks for a revision, the whole thing or any provision of it, in writing. They have to name the language they want added or deleted and back the request with new evidence that could materially affect the content, with copies of the published evidence included.² Then the contractor has 60 calendar days to determine whether the reconsideration request is valid.²
What reconsideration won't touch: national determinations, coverage provisions in interpretive manuals, proposals like me, retired documents, individual claim decisions, bulletins and articles and training materials, and any situation where no local determination exists at all.²
That last one catches people.
"Please write one" is a brand-new request, not a reconsideration.
Contractors can also revise or retire on their own initiative, any time.²
Challenge is something else entirely, and the key is held by exactly one kind of person: an aggrieved party.
An "aggrieved party" is a Medicare beneficiary, or the estate of one, entitled to Part A or enrolled in Part B, who needs coverage for an item or service that would be denied under the determination — as documented by their treating physician — whether or not the service has already been received.²
Not the hospital. Not the manufacturer. The patient, with a note from their doctor.
And when a document like me is finally retired, the record doesn't disappear. It's kept a minimum of six years and three months.²
What This Means Monday Morning
"...can I write to you?"
Yes. That's the entire point of me sitting here.
For a wound care program, the practical version comes down to four habits:
Know which document you're holding.
A final determination, a proposal, a coding article, and a Response to Comment are four different documents with four different jobs. A proposal isn't policy. A coding article isn't clinical criteria. A comment isn't a determination.
Read the tracking sheet.
Every proposal carries a tracking sheet. It tells you the issue, who requested it, the process dates, links to the key documents, and who to contact.¹ It's the fastest way to learn whether something that affects your service line is moving, stalled, or already decided.
Comment in writing.
Comment in writing, but think like a requestor. The strongest comments do what a formal request needs to do: name the requested language, and attach peer-reviewed evidence.² Contractors weigh published original research, systematic reviews and meta-analyses, evidence-based consensus statements, and clinical guidelines. Proprietary information not available to the public isn't considered at all.² The bibliography follows the American Medical Association Manual of Style² — which means the final document tells you exactly what evidence the contractor read.
Check the window before assuming the door is shut.
Forty-five days is the floor, not the ceiling. And an empty mailbox is right there waiting. So if something matters to your program, don't assume somebody else will say it for you.
SHS Insight: Many wound care programs spend real time, energy, and resources on coverage and documentation gaps. There's a third gap that gets less attention: knowing which document answers the question. A denial can look clinical when the problem is administrative — the wrong coverage document, the wrong coding article, the wrong jurisdiction, or a proposal treated like final policy.
Shared Health Services works alongside wound care and hyperbaric oxygen therapy (HBOT) programs to identify the documents governing their services, build documentation around the reasonable-and-necessary structure those policies actually use, and track proposed changes before they become effective. We support the people doing the work. The coverage decision remains with the payer and the policy governing it.
The system was built with doors in it. Somebody just has to notice the doors.
It's 5:15 now. The tabs are still open.
I'm just a determination. Yes, I'm only a determination.
There are fourteen days left, and the mailbox is still empty.
Somebody could write.
To talk through which documents govern your wound care or hyperbaric oxygen therapy (HBOT) program, contact Shared Health Services at (800) 474-0202 or sales@sharedhealthservices.com.
References
Centers for Medicare & Medicaid Services. Medicare coverage document type descriptions. Updated December 14, 2023. Accessed August 12, 2026. https://www.cms.gov/medicare-coverage-database/help/Document_Type_Descriptions.pdf
Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual. Pub. 100-08, chapter 13: Local coverage determinations. Rev. 863; issued February 12, 2019. Accessed August 12, 2026. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c13.pdf
Centers for Medicare & Medicaid Services. What's a MAC. Updated July 8, 2026. Accessed August 12, 2026. https://www.cms.gov/medicare/coding-billing/medicare-administrative-contractors-macs/whats-mac
