MAC Jurisdictions for Cardiology: LCD Basics

The seven MACs and their footprints

Medicare Administrative Contractors split the US into jurisdictions. Each MAC administers Medicare Part A and Part B for its territory and publishes its own Local Coverage Determinations.

• Novitas Solutions — Colorado, New Mexico, Oklahoma, Texas, Arkansas, Louisiana, Mississippi, Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania
• First Coast Service Options — Florida, Puerto Rico, US Virgin Islands
• Palmetto GBA — North Carolina, South Carolina, Virginia, West Virginia, plus JJ/JM contract areas
• WPS Government Health Administrators — Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, Wisconsin
• Noridian Healthcare Solutions — Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming
• CGS Administrators — Kentucky, Ohio
• National Government Services (NGS) — Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont

Jurisdiction assignments can change; the current mapping is published on the CMS website.

What an LCD contains

Every Local Coverage Determination includes:

• Covered indications (typically listed as ICD-10 diagnosis codes)
• Non-covered indications
• Frequency limits (for repeat services)
• Documentation requirements
• Utilization guidelines
• Coding guidelines
• ICD-10 codes that support medical necessity
• Effective date
• Revision history

The LCD is the primary reference the MAC's medical reviewers apply when adjudicating claims. Documentation not mapping to an LCD-listed indication triggers medical-necessity denials.

The highest-denial-volume cardiology LCDs

Stress testing

Coverage criteria for stress echocardiography (CPT 93350, 93351), nuclear stress testing (CPT 78451-78454), and exercise stress ECG (CPT 93015-93018) vary between MACs. The clinical indications that qualify differ; some MACs cover stress testing for chest pain evaluation only when specific risk factors are documented, others cover asymptomatic screening in higher-risk populations. Billing teams working across MAC jurisdictions frequently see denials when documentation prompts were designed for one MAC's LCD but not another's.

Echocardiography frequency

Most MACs allow one complete transthoracic echocardiogram per 90-180 days for stable cardiac conditions without additional documentation. Repeat studies within that window need clinical-trigger documentation: new symptom, medication change, post-procedure follow-up, or acute cardiac event. Automatic repeat echos ordered on schedule without clinical-trigger documentation are the primary source of frequency denials.

Elective PCI

Elective PCI for stable ischemic heart disease (SIHD) has evolving LCD coverage criteria across MACs. Documentation typically must include the ischemic burden on noninvasive testing, medication trial history, symptom severity, and shared decision-making documentation. Denials tend to cluster on cases with borderline ischemic burden or minimal medication trial before intervention.

Telemedicine

Cardiology telemedicine LCDs have been in flux since the 2020 public health emergency policy expansions began sunsetting. Coverage for follow-up visits, initial consultations, and remote monitoring interpretation varies by MAC and by service type. Billing teams should audit current telemedicine LCDs quarterly through the CMS coverage database.

How to keep the LCD library current

The CMS Medicare Coverage Database (cms.gov/medicare-coverage-database) is the primary source. Search by state or MAC and by CPT code to retrieve the current LCD. Subscribe to the MAC's email update lists for real-time notification of LCD revisions. Audit active procedure LCDs at least quarterly.

Effective dates matter procedurally: a service performed before an LCD update follows the prior LCD, even if the claim is adjudicated after the update. Billing teams disputing denials on that basis have appeal grounds when the payer applied a new LCD retroactively.

The economic case for MAC-specific expertise

A cardiology billing team with mature MAC-jurisdiction LCD knowledge typically operates 3-6 percentage points below the industry-average cardiology denial rate. On a $2M practice, that six-point difference (going from 17% to 11% denial rate) protects roughly $120,000 in first-pass revenue. Recovery through appeals partially closes the gap but the net revenue advantage typically remains $50,000-$80,000 annually per $1M in collections.