2024 Medicare Advantage Final Rule — AI in Coverage Determinations
United States (Federal) | CMS-4201-F
Categories
Key Requirements
Establishes that prior authorization may only be used for medical necessity determinations based on diagnoses and clinical criteria. MA organizations may use AI in coverage determinations only if they comply with all regulatory requirements, including individualized determinations based on patient circumstances. Denials of basic benefits must be based solely on publicly available coverage criteria.
Regulated Parties
Medicare Advantage organizations; Part D plan sponsors; PACE organizations
Enforcement
CMS; HHS Office of Inspector General
Sources
Notes
Does NOT ban AI in prior authorization but requires individualized patient review. CMS issued AI-specific FAQs on February 6, 2024.
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