Question · CMS
How do I show my utilization-management algorithm assessed the individual patient?
CMS-4201-F requires Medicare Advantage plans to base medical necessity decisions on the individual enrollee's medical history, physician recommendations and clinical notes, follow Traditional Medicare coverage rules, and have a qualified clinician review any adverse decision.
01 / The answer
The short answer
Keep a case record showing that each decision turned on the patient's own facts, not only a model score. For each determination, record the medical history, physician recommendations and clinical notes considered; the coverage criteria applied, whether Medicare NCDs and LCDs or publicly posted internal criteria; the tool's limited role; and the name and expertise of the physician or professional who reviewed any denial. Your UM committee must also approve every UM policy, review them at least annually and document its reasons in writing for CMS on request (42 CFR 422.137).
02 / The rule
What CMS requires
CMS-4201-F requires Medicare Advantage plans to base medical necessity decisions on the individual enrollee's medical history, physician recommendations and clinical notes, follow Traditional Medicare coverage rules, and have a qualified clinician review any adverse decision. CMS's February 2024 FAQ applies this to AI: plans may use algorithms to assist, but not as the sole basis for denying or ending care.
- 01Base each medical necessity decision on the enrollee's own medical history, physician recommendations and clinical notes (42 CFR 422.101(c)(1)).
- 02Follow Traditional Medicare NCDs and LCDs; use internal criteria only when coverage is not fully established, publicly posted and evidence-based.
- 03Have a physician or appropriate professional with relevant expertise review any expected adverse medical necessity decision before issuing it.
- 04Have a physician-led utilization management committee approve and annually review all UM and prior authorization policies.
03 / Records
Records to keep
- 01Case files showing individual records reviewed for each adverse decision
- 02Clinician person reviewing it credentials and sign-off on denials
- 03UM committee minutes approving algorithm-supported policies
- 04Published internal coverage criteria with supporting evidence
Optional evidence · where Planisphere fits
Keep a record anyone can check
When your team meets a duty, Planisphere can seal the event it reports as a receipt.
A disclosure shown, a review signed, a model change approved: the event your system reports.
The event becomes a sealed receipt, dated and attributed to whoever is signed in.
Paste the receipt into Verify. No account or key.
A record supports your compliance evidence process. It is not a legal finding or a certification. Systems that call Planisphere's gate API can also hold or refuse an action before it runs.
SOURCES
Go back to the source
Federal Register (CMS)
CMS Innovation Center
RELATED
Related: CMS: the full guide · Can a Medicare Advantage plan use AI to deny coverage?