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POST
LCD/NCD medical-necessity coverage check

Authorizations

X-API-Key
string
header
required

Body

application/json

LCD/NCD medical-necessity coverage check for a claim's procedure lines.

Coverage-only: this evaluates whether each procedure's diagnoses satisfy the applicable Medicare local (LCD) and national (NCD) coverage determinations. It does NOT run NCCI, MUE, timely filing, or payment.

lines
EncounterCoverageLine · object[]
required

Procedure lines to evaluate

Required array length: 1 - 50 elements
claim_type
string
default:professional

professional (per-line DX) or institutional (claim-level DX)

date_of_service
string | null

Date of service (YYYY-MM-DD)

dx
EncounterDiagnosis · object[]

Claim-level ICD-10 diagnoses (837 loop 2300 HI). Applied to every line for institutional claims; used as a fallback for professional lines that carry no DX. The ABK-qualified (or first-listed) entry is the principal diagnosis.

payer
string | null

Reserved: payer overlay on top of the Medicare base layer. Not yet applied — non-Medicare values return the Medicare base with a warning.

state
string | null

2-letter state → MAC jurisdiction for LCD localization (NCDs are national)

Response

Successful Response

Coverage-only medical-necessity assessment for a claim.

claim_type
string
required
coverage_clean
boolean
required

True when no line has a coverage blocker (dx_not_on_lcd/dx_required/not_covered)

contractor_id
string | null

Resolved MAC jurisdiction, e.g. JL

coverage
EncounterCoverageResult · object[]
date_of_service
string | null
state
string | null
warnings
EncounterWarning · object[]