CurrentKaiser PermanentePolicy N/A

Medicare Medical Policy Development — Evidence Hierarchy for Coverage Decisions

Defines the hierarchy and evidence requirements Kaiser Permanente Medicare Advantage uses to develop medical policies determining when services are reasonable and necessary for Medicare Advantage members; applies to Kaiser Permanente Medicare Advantage policy authors, reviewers, and clinicians making coverage determinations.

Policy Summary

PayerKaiser Permanente

PolicyMedicare Medical Policy Development — Evidence Hierarchy for Coverage Decisions

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFollow applicable NCDs and LCDs and, when none exist, apply the stated hierarchy and provide objective evidence-based rationale for coverage determinations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

hierarchyprioritized evidence sources

CMS-alignedpolicy basis

MolDXgenetics handling

MPC reviewedcommittee activity

Coverage Criteria and Evidence Hierarchy

Policy Development and Evidence Hierarchy

Apply the following hierarchy when determining coverage for a service:

Hierarchy Order: 1) Use CMS Coverage Manuals and other CMS-based resources (e.g., MLN, Federal Register) when available;

CMS coverage manuals and CMS-based resources are the first source; interpretive manuals define when items or services may be covered.

Hierarchy Order: 2) Apply National Coverage Determinations (NCDs) when present (NCDs are binding on all Medicare Advantage plans).

NCDs take precedence and are applied nationally once published in a CMS program instruction.

Hierarchy Order: 3) If no applicable NCD, apply Local Coverage Determinations (LCDs), Articles (LCA), and other contractor-based bulletins from the relevant Medicare Administrative Contractor (MAC).

When an LCD covers all claims for a specific item/service nationwide (single MAC provider situation), MA plans must follow that LCD for that item/service.

Policy Summary

PayerKaiser Permanente

PolicyMedicare Medical Policy Development — Evidence Hierarchy for Coverage Decisions

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFollow applicable NCDs and LCDs and, when none exist, apply the stated hierarchy and provide objective evidence-based rationale for coverage determinations.

SourceLink

On This Page

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Hierarchy Order: 4) Consider retired LCDs as background only (they may be informative but are not primary coverage criteria).

Retired LCD guidance may still help assess medical necessity but does not replace active NCD/LCD guidance.

Hierarchy Order: 5) When no NCD or LCD exists, consider other authoritative evidence in this order: MAO policies from other plans in the service area, objective evidence from government agencies (e.g., FDA), independent technology assessments (e.g., ECRI, AHRQ, Blue Cross Blue Shield TEC), well-designed peer-reviewed clinical studies, and MCG Care Guidelines as needed.

MAO must make its own coverage determination and provide CMS an objective evidence-based rationale; conclusory statements without rationale are not acceptable.

Special-case handling: For genetic and molecular diagnostic tests, apply MolDX guidelines (Palmetto GBA) for the applicable jurisdiction when available; if no MolDX guideline exists, apply the hierarchy above.

MolDX guidelines should be applied to requests for genetic/molecular testing in the specified jurisdictions.

Retired Local Coverage Determinations (LCDs) are not treated as primary coverage criteria because they may no longer reflect current clinical guidance. They can be referenced for historical context or background, but coverage determinations must be based on the authoritative hierarchy of evidence and current CMS guidance.

Kaiser Permanente may determine that a procedure or device has insufficient evidence for coverage even when the item has received FDA approval. The term insufficient evidence indicates that, based on Kaiser Permanente's objective, evidence-based technology assessment and authoritative evidence sources, the service or device has not demonstrated safety or superior long-term outcomes versus standard therapies.

Provider Responsibilities and Operational Rules

Note

Follow NCD/LCD hierarchy for coverage decisions

Coverage determinations must follow applicable CMS guidance. When a National Coverage Determination (NCD) or Local Coverage Determination (LCD) applies, the MA organization must follow that guidance. If no NCD or LCD exists, Kaiser Permanente will apply the established hierarchy of evidence-based sources (CMS manuals and interpretive guidance, authoritative technology assessments, peer‑reviewed literature, MCG guidelines, and other MAO policies) to make a coverage determination.

Follow applicable NCDs and LCDs first
If no NCD/LCD exists, apply CMS manuals, independent technology assessments, peer‑reviewed studies, MCG guidelines, or other authoritative evidence

Note

Use of cost‑effective provider options

MA plans may encourage use of more cost‑effective provider types or care pathways when consistent with Medicare coverage and provider licensure/scope rules. Cost‑effective delivery options are allowed provided the plan complies with provider anti‑discrimination rules (42 CFR §422.205) and does not alter Medicare coverage requirements: if Original Medicare limits coverage to specific conditions, those conditions still govern the MA benefit unless the plan elects to offer supplemental coverage.

Encourage licensed providers working within their scope of practice
Do not replace Medicare coverage conditions — services meeting Original Medicare limitations remain subject to those conditions
Benefits provided outside Medicare conditions are supplemental

Documentation Required

Support requests with CMS/NCD/LCD‑aligned documentation

Providers must submit clinical documentation that aligns with CMS guidance and any applicable NCDs or LCDs. When no NCD/LCD exists, documentation should cite the authoritative evidence used (e.g., CMS manuals, independent technology assessments, peer‑reviewed studies, FDA determinations, MCG guidelines) to support medical necessity.

Include citations to CMS manuals, NCDs/LCDs, independent technology assessments, peer‑reviewed studies, or MCG where applicable
Provide objective, evidence‑based rationale for requested services

Denial Risk

Rationale required for denials

Denials must be supported by an objective, evidence‑based rationale that references applicable CMS guidance or other authoritative evidence. Conclusory statements without supporting rationale (e.g., “It is our policy to deny coverage for this service.”) are not acceptable.

Cite applicable NCD, LCD, CMS manual, or peer‑reviewed evidence in denial rationale
Do not use conclusory denials without objective supporting evidence

Background and Scope

Medicare Advantage plans must provide the same Medicare-covered benefits as Original Medicare; therefore Kaiser Permanente policy development relies on CMS materials and follows a defined hierarchy of evidence. That hierarchy prioritizes CMS coverage manuals and NCDs, then LCDs and contractor guidance, and when no CMS determinations exist, considers other authoritative sources such as independent technology assessments, well-designed peer-reviewed studies, and MCG guidelines.

Key Definitions

National Coverage Determination (NCD)

DefinitionA CMS policy applied nationally that is binding on all Medicare Advantage plans and defines coverage for particular services or technologies.

ScopeApplies on a national basis to all Medicare beneficiaries and is binding once published in a CMS program instruction.

Priority in hierarchyNCDs are used after CMS Coverage Manuals and other CMS-based resources and take precedence over LCDs within the policy hierarchy.

When to useUse NCDs whenever CMS has issued one for a service, procedure, or technology; an NCD governs coverage determinations for Medicare Advantage members.

Source examplesPublished in CMS program instructions and may be referenced alongside CMS interpretive manuals and MLN/Federal Register publications.

Local Coverage Determination (LCD)

DefinitionCoverage guidance developed by a Medicare Administrative Contractor when no NCD exists, applicable within the contractor's jurisdiction and used to define medical necessity.

JurisdictionApplicable within the MAC service area that issued the LCD (for example, Noridian is the designated MAC for Washington).

Use caseUsed when there is no NCD or when further definition of an NCD is needed; may include Articles (LCA) and other contractor-based bulletins.

Retired LCDsRetired LCDs may be retired due to lack of current utilization issues or because the topic is addressed by an NCD or CMS manual; retired LCDs may still be useful background but are not primary coverage criteria.

Relationship to MAO policiesIn absence of NCD/LCD guidance, an MAO may adopt coverage policies of other MAOs in its service area, but LCDs remain the primary contractor-issued guidance when present.