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PolicyHealthFinanceUSConfirmed

CMS tells Medicare Advantage plans AI cannot replace individual coverage decisions

See how this story connects

Source: CMS memo: FAQs on Coverage Criteria and Utilization Management Requirements in CMS-4201-F (copy hosted by the American Hospital Association)Also reported by Reed Smith

In a memo to all Medicare Advantage organisations dated 6 February 2024, CMS said plans may use algorithms and AI to assist coverage determinations but remain responsible for complying with the 2024 rule (CMS-4201-F). Decisions on medical necessity must rest on the individual patient’s history, physician recommendations and clinical notes, and a tool that decides coverage from a larger data set without those does not comply. Plans must also check that algorithms do not introduce or worsen bias.

Why it matters

Medicare Advantage insurers using prediction tools for prior authorisation now had written CMS limits: AI can assist a decision but cannot set coverage without an individual review.

When
6 Feb 2024
ID
WTA-N-2024-0005
Who
CMS

Summary by wheresthe.ai, from CMS memo and the reporting credited above. Checked against the source on 9 Oct 2026.

Read the original at CMS memo

Source copy: download the source PDF as saved on 18 Oct 2026 (PDF). Document the source offers: the source PDF. Also held by the Internet Archive.

Next stop on this Storyline: Led toSenate report links insurer automation to rising Medicare Advantage post-acute denials

Cite this story

WTA-N-2024-0005: “CMS tells Medicare Advantage plans AI cannot replace individual coverage decisions.” wheresthe.ai, 6 Feb 2024. https://wheresthe.ai/d/us-cms-medicare-advantage-ai-faq-2024-02/ (source: CMS memo: FAQs on Coverage Criteria and Utilization Management Requirements in CMS-4201-F (copy hosted by the American Hospital Association)).

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