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CMS Medicare Advantage rules, 42 CFR 422.101(c)(1)(i) and 422.566(d)

Centers for Medicare & Medicaid Services · pack 0.2.0 · verified against the official source as of 2026-10-04. AI-adjacent group: general privacy or biometric law, included only where AI data flows trigger it. Open it in the explorer.

Binding law — in force

Base Medicare Advantage medical necessity determinations on the enrollee's own history, physician recommendations and notes (42 CFR 422.101(c)(1)(i))

MA organizations must make medical necessity determinations based on all of: Medicare coverage and benefit criteria (and may not deny basic benefits on criteria not specified in 422.101(b) or (c)), whether the item or service is reasonable and necessary under section 1862(a)(1) of the Act, the enrollee's medical history (for example diagnoses, conditions, functional status), physician recommendations and clinical notes, and, where appropriate, the medical director's involvement (42 CFR 422.101(c)(1)(i)(A)-(D)). The rule never mentions AI; it is encoded as AI-adjacent (owner decision D-19, D-11 pattern 1) because algorithmic and AI review tools that predict outcomes from group data are where determinations without the individual record arise. Detect a utilization-review model or scoring call whose inputs never include the enrollee's own clinical record.

us-cms-ma-medical-necessity.determination-on-individual-medical-history · 42 CFR 422.101(c)(1)(i) · official source · jurisdictions: US

The guard to add, and how far to trust this rule

Binding law — in force

A physician or other appropriate professional reviews every expected adverse Medicare Advantage medical necessity decision first (42 CFR 422.566(d))

If an MA organization expects to issue a partially or fully adverse medical necessity decision based on the initial review of a request, the organization determination must be reviewed, before it issues, by a physician or other appropriate health care professional with expertise in the field of medicine or health care appropriate for the services at issue, including knowledge of Medicare coverage criteria, holding a current and unrestricted license (42 CFR 422.566(d)). The rule never mentions AI; it is encoded as AI-adjacent (owner decision D-19, D-11 pattern 1) because AI and algorithmic review tools are where denials without that review arise. Detect utilization-review code where model output reaches a denial with no physician or clinical review step.

us-cms-ma-medical-necessity.physician-reviews-adverse-medical-necessity-decision · 42 CFR 422.566(d) · official source · jurisdictions: US

The guard to add, and how far to trust this rule