RARC N115: Decision Based on National Coverage Determination
The payer's decision on this claim was based on a Medicare National Coverage Determination — review the specific NCD to understand the coverage criteria and determine if your claim meets the requirements.
What Does RARC N115 Mean?
RARC N115 is an informational remark indicating that a National Coverage Determination (NCD) was the basis for the payer's adjudication decision on this claim. NCDs are Medicare-wide coverage policies issued by CMS that define whether and under what circumstances Medicare will cover specific items, services, or technologies. They override any local coverage determinations and apply uniformly across all Medicare contractors.
When N115 appears, the claim may have been paid, reduced, or denied — the code itself does not specify the outcome, only that an NCD drove the decision. If the claim was denied, the NCD likely has specific coverage criteria (such as diagnosis requirements, patient conditions, or frequency limits) that the claim did not satisfy. If the claim was paid but at a different amount than expected, the NCD may restrict coverage to certain circumstances or limit the allowable frequency.
N115 is often paired with other codes that provide more detail about the specific issue. It serves as a pointer to tell the billing team where to look for the policy rationale behind the decision, which is essential for determining whether an appeal would be successful.
What to Do
Identify the specific NCD that applies to the billed service. You can search the CMS Medicare Coverage Database at cms.gov by procedure code, diagnosis, or keyword. Once you find the relevant NCD, review its coverage criteria carefully — including required diagnoses, patient conditions, provider qualifications, and any frequency or setting restrictions.
If the claim was denied and you believe the service meets the NCD criteria, gather documentation demonstrating compliance with each requirement and submit an appeal. Include the specific NCD number in your appeal letter and address each coverage criterion individually. If the service genuinely does not meet the NCD criteria, the denial will likely stand, but you may explore whether an Advanced Beneficiary Notice (ABN) was obtained that allows billing the patient.
Common Scenarios
- A claim for a screening colonoscopy is denied because the patient does not meet the age or risk factor criteria specified in the applicable NCD
- An implantable device claim is reduced because the NCD limits coverage to specific clinical indications that differ from the diagnosis reported
- A lab test is denied because the NCD requires it to be ordered only for patients with specific documented conditions, and the claim's diagnosis codes do not match
- A therapy service claim is processed at a lower rate because the NCD caps the covered frequency to a specific number of sessions per year
Commonly Paired With
RARC N115 commonly appears alongside these CARC denial codes: