RARC N115: Decision Based on Local Coverage Determination (LCD)
This remark means the payer's decision was made under a Local Coverage Determination (LCD) — a coverage policy written by the Medicare Administrative Contractor (MAC) for its specific jurisdiction, not a nationwide CMS rule.
What Does RARC N115 Mean?
N115 tells the billing specialist that the adjustment on the claim traces back to an LCD: a coverage policy issued by the MAC that processed the claim, applicable only within that MAC's jurisdiction. LCDs spell out the diagnoses, frequency limits, documentation requirements, or medical-necessity criteria a service must meet to be covered in that region. Because each MAC develops and maintains its own LCDs, coverage for the same CPT/HCPCS code can differ from one jurisdiction to another — a service that is routinely paid in one MAC's territory may be denied or restricted in another if the two MACs have written different local policies.
N115 most often accompanies a CARC that communicates the financial effect of the LCD-based decision — for example a denial for lack of medical necessity, a frequency-limit adjustment, or a non-covered-service determination. The remark itself doesn't state the reason for non-coverage; it points the biller to the fact that a local (not national) policy drove the outcome, which is the cue to go look up the specific LCD rather than assume a global Medicare rule was applied.
Because LCDs are jurisdiction-specific and are revised periodically, a claim that was paid last year — or that would be paid under a different MAC — can still be denied today under the LCD currently in force for the jurisdiction that adjudicated it. This is a normal feature of Medicare's local coverage process, not necessarily an indication that the claim was submitted incorrectly.
What to Do
Identify which MAC processed the claim and pull the specific LCD referenced (or most plausibly applicable) for the service billed — CMS's Medicare Coverage Database lets you search by MAC jurisdiction, CPT/HCPCS code, and diagnosis. Compare the LCD's covered-diagnosis list, frequency limits, and documentation requirements against what was submitted on the claim to find the gap that triggered the adjustment.
If the documentation in the chart actually supports the LCD's criteria but wasn't reflected on the claim (e.g., a qualifying diagnosis code was omitted or a required modifier was missing), correct and resubmit. If the service genuinely doesn't meet the local criteria, evaluate whether an Advance Beneficiary Notice (ABN) should have been obtained, or whether the claim is a candidate for appeal with supporting clinical documentation. Because LCDs vary by jurisdiction, don't assume a coverage rule that applied under a different MAC will hold here — always confirm against the specific jurisdiction's current LCD.
Common Scenarios
- A DME item is denied for a Medicare patient because the MAC's LCD requires a specific qualifying diagnosis or documented trial of conservative treatment that isn't present on the claim.
- A diagnostic test billed at a frequency higher than the local MAC's LCD allows within a set time window is reduced or denied, even though the same frequency would be covered under a neighboring MAC's policy.
- A therapy service is adjusted because the submitted diagnosis code isn't on the covered-diagnosis list in that jurisdiction's LCD, prompting the biller to check whether a more specific, LCD-supported diagnosis applies.
- A practice that bills across multiple MAC jurisdictions sees the same procedure code paid in one region and denied with N115 in another, reflecting differing local coverage policies rather than a data-entry error.
Commonly Paired With
RARC N115 commonly appears alongside these CARC denial codes: