Can a Medicare Advantage plan use AI to deny coverage?
CMS guidance (notably the 2024 MA rule and follow-on FAQs) is clear that an algorithm or AI tool cannot be the sole basis to deny or terminate coverage — a Medicare Advantage plan must base medical-necessity decisions on the individual patient's circumstances…
Answer.
CMS guidance (notably the 2024 MA rule and follow-on FAQs) is clear that an algorithm or AI tool cannot be the sole basis to deny or terminate coverage — a Medicare Advantage plan must base medical-necessity decisions on the individual patient's circumstances and applicable coverage criteria, with the tool only as an aid. AI may inform, not replace, the individualized determination. Planisphere can evidence how a utilization-management model behaves; it does not make or certify the coverage decision.
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Medicare/Medicaid coverage · algorithm cannot be the sole basis to deny care.
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Start with the free sandbox. Planisphere measures model behaviour and emits a reproducible, sha-pinned record — it does not certify, file, or give legal advice.