Medicare Coverage Lookup Tool

Fast, structured search across the CMS Medicare Coverage Database. Find which ICD-10 diagnoses support medical necessity for any CPT or HCPCS procedure code, check MAC jurisdiction requirements, and identify prior authorization flags.

How it works

• Search by CPT code, HCPCS Level II code, or ICD-10-PCS procedure code to see every ICD-10-CM diagnosis that CMS accepts as supporting medical necessity.
• Search by ICD-10 diagnosis code to find every Medicare-covered procedure that lists it as covered or non-covered.
• Filter by Medicare Administrative Contractor (MAC) jurisdiction, coverage status, and care setting (outpatient or inpatient).
• Prior authorization flags highlight DMEPOS and OPD procedure codes requiring CMS prior authorization, with direct links to the source CMS billing and coding article.

What's in the database

• Local Coverage Determinations (LCDs) — search and browse Medicare LCD policies by title
• National Coverage Determinations (NCDs) — nationwide Medicare coverage policies
• 6.8 million+ covered and non-covered ICD-10 to procedure code pairings from CMS billing articles
• 3,000+ CPT, HCPCS Level II, and ICD-10-PCS procedure codes with full descriptions
• 57,000+ ICD-10-CM diagnosis codes with descriptions and procedure cross-references
• Jurisdiction and MAC mapping — filter coverage by state and contractor
• CMS prior authorization required-codes lists (DMEPOS and Outpatient Department)
• Weekly automated data refresh every Thursday from the CMS Medicare Coverage Database

Coming soon

• Medicare fee schedules (Physician Fee Schedule, OPPS, ASC, DMEPOS, Clinical Lab)
• NCCI Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUE)
• LCD/NCD change alerts — get notified when coverage policies are revised
• Modifier and place-of-service code lookups
• Bulk lookup and CSV export for batch medical necessity verification
• JSON API access for EHR, RCM, and prior authorization integrations

Who CMS Explorer is for

Medical billers and coders use CMS Explorer to verify that a procedure code and diagnosis code pairing meets Medicare medical necessity requirements before submitting claims. Instead of navigating the CMS Medicare Coverage Database and reading LCD and NCD policy PDFs, search by CPT code, HCPCS code, or ICD-10 diagnosis and get instant results.

Revenue cycle management (RCM) teams use CMS Explorer to reduce claim denials by checking coverage policies upfront. Filter by MAC jurisdiction to see only the Local Coverage Determinations that apply to your region, and flag procedures requiring prior authorization.

Prior authorization specialists use CMS Explorer to identify which DMEPOS and outpatient department procedure codes require prior authorization, and to verify supporting diagnoses meet medical necessity criteria.

Healthcare software developers building EHR integrations, AI coding assistants, or claims adjudication systems can use the upcoming CMS Explorer API to programmatically query Medicare coverage data, procedure-diagnosis pairings, and prior authorization requirements.

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CMS Explorer is not affiliated with or endorsed by the Centers for Medicare & Medicaid Services. Data sourced from the CMS Medicare Coverage Database.