Manatt Health February 22, 2024
Apparently in light of recent litigation against Medicare Advantage (MA) plans, on February 6, 2024, CMS published responses to frequently asked questions (FAQs) regarding the use of algorithms and artificial intelligence in coverage determinations. The FAQs clarify that MA plans can use algorithms and software tools, including AI, to assist in decisions as long as all regulatory requirements are met, including, in the case of adverse medical necessity determinations, individualized determinations based upon a patient’s circumstances.1
As set forth in the April 5, 2023 final rule concerning, among other things, MA coverage criteria for basic benefits and the use of prior authorization, in making coverage determinations, MA plans must take into account individual circumstances, including medical history and physician recommendations....
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