CurrentKaiser PermanentePolicy N/A

Medicare Medical Policy Development Hierarchy

Defines the hierarchy and evidence requirements Kaiser Permanente Medicare Advantage uses to develop Medicare Advantage medical policies and how coverage determinations are made for Medicare Advantage members.

Policy Summary

PayerKaiser Permanente

PolicyMedicare Medical Policy Development Hierarchy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2015

Next Review DateN/A

Key ActionWhen no NCD/LCD/CMS guidance exists, make a coverage determination supported by an objective evidence-based rationale citing authoritative evidence.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6policy source tiers

AppliesNCDs binding on MA

Noridian/MolDXMolDX for molecular tests

Objective rationaleEvidence requirement

Coverage Determination Principles

Coverage Determination Hierarchy

Determine coverage by applying the following hierarchy in order:

Tier 1: Apply CMS Coverage Manuals and other CMS-based resources (e.g., Medicare Learning Network, Federal Register) when available.

CMS interpretive manuals further define coverage provisions.

Tier 2: Apply National Coverage Determinations (NCDs), which are binding on Medicare Advantage plans once published.

Tier 3: Apply Local Coverage Determinations (LCDs), Articles (LCA), and other contractor-based bulletins when no applicable NCD exists or when further definition is needed.

MAC-specific guidance (e.g., Noridian) may apply to the service area; in some cases an A/B MAC LCD that processes all claims for an item/service must be followed.

Policy Summary

PayerKaiser Permanente

PolicyMedicare Medical Policy Development Hierarchy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2015

Next Review DateN/A

Key ActionWhen no NCD/LCD/CMS guidance exists, make a coverage determination supported by an objective evidence-based rationale citing authoritative evidence.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Responsibilities and Operational Rules

Prior Authorization

Prior authorization governed by governing policy

Prior authorization and other pre-service review requirements are governed by the applicable Kaiser Permanente governing policy and by CMS rules. When CMS coverage manuals, a National Coverage Determination (NCD), or a Local Coverage Determination (LCD) apply, those resources control the prior authorization and operational rules. Providers should follow the payer's prior authorization procedures and recognize that prior authorization decisions and related operational requirements will align with CMS manuals, NCDs, LCDs, and applicable Medicare Advantage policy.

Applies to services subject to Medicare coverage rules
Prior authorization determinations follow CMS manuals, NCDs, LCDs, and MA policy

Denial Risk

Evidence-based rationale required

When Kaiser Permanente makes a coverage determination in the absence of an applicable NCD or LCD, the organization must provide an objective, evidence-based rationale. Denials or coverage limits may not be based on conclusory statements without supporting evidence. Providers can expect justifications that cite authoritative sources such as government agency studies, independent technology assessments, or well-designed peer-reviewed clinical studies.

MAO must provide objective evidence-based rationale when no NCD/LCD exists
Conclusive denials without rationale (e.g., 'It is our policy to deny coverage for this service') are not permitted
Authoritative evidence examples: FDA studies, independent technology assessments (BCBSA), peer-reviewed clinical trials

Documentation Required

Documentation and evidence expectations

Providers are expected to document clinical information consistent with CMS manuals, NCDs, and LCDs. When Kaiser Permanente issues its own coverage criteria, determinations will include an objective, evidence-based explanation and reference to the supporting materials. Maintain thorough clinical records and submit the specific documentation cited in authorization or appeal requests so reviewers can apply the stated evidence-based criteria.

Provide clinical records that directly support the requested service and reference applicable CMS/NCD/LCD criteria when cited
If the MAO applies its own criteria, expect a written rationale citing the authoritative evidence used
Do not rely on conclusory statements — supply objective data, studies, or guideline excerpts requested by reviewers

Context and Purpose

This policy explains the sources and evidentiary standards Kaiser Permanente Medicare Advantage uses to determine medical necessity for Medicare Advantage members. Coverage determinations follow a tiered approach: apply CMS coverage manuals and resources first, then binding National Coverage Determinations (NCDs), then Local Coverage Determinations or contractor guidance when applicable, and when no CMS guidance exists the MAO may adopt other MAO commercial policies or make its own determination. If making an independent determination, the MAO must provide an objective evidence‑based rationale citing authoritative sources such as FDA studies, independent technology assessments, or well‑designed controlled clinical studies; MCG Care Guidelines may be used as a fallback at the discretion of the physician reviewer.

Key Definitions

inv-08: National Coverage Determination (NCD)

DefinitionA CMS-issued coverage determination applied nationally for all Medicare beneficiaries; once published in a CMS program instruction the NCD is binding on all Medicare Advantage plans.

ScopeApplies nationally to all Medicare beneficiaries and takes precedence over MAC-issued guidance when available.

Role in hierarchyTier 2 in Kaiser Permanente's Medicare Advantage policy hierarchy — applied after CMS Coverage Manuals and before LCDs.

When to applyUse an NCD whenever CMS has published a determination for the service, procedure, or technology under review.

inv-09: Local Coverage Determination (LCD)

DefinitionCoverage guidance developed by a Medicare Administrative Contractor (MAC) for a specific service area when no applicable NCD exists or when further definition of an NCD is needed.

ScopeUsed to define medical necessity within the MAC's jurisdiction; MA plans must follow an LCD when the MAC that enrolled the provider processes all claims for that item or service nationally.

When to applyApply an LCD when there is no NCD or when additional detail is required to interpret an NCD; Noridian is the designated MAC for Washington.

Form examplesIncludes LCDs, Local Coverage Articles (LCA), and other contractor-based bulletins or Part B News Articles from the MAC website.

inv-10: MolDX

DefinitionMolDX is the Molecular Diagnostic program (Palmetto GBA) whose guidelines have been implemented by Noridian for genetic and molecular diagnostic testing in Jurisdiction F.

ApplicationMolDX guidelines, when available, should be applied to requests for genetic and molecular diagnostic testing in Noridian's Jurisdiction F service area.

FallbackIf no MolDX guideline exists for a specific genetic test, the standard Kaiser Permanente Medicare Advantage hierarchy (NCD, LCD, retired LCD, other policies, MCG) applies.

Authority relationshipNoridian (the MAC) uses Palmetto GBA's MolDX guidance as the controlling molecular diagnostic guidance within J-F for MA coverage decisions.