Medicare Posts Final Rule for 2024 Policy Changes to Medicare Advantage Plans – Review of Medical Necessity Requirements

Medicare Advantage Plans

Medicare has finalized its 2024 policies for the Medicare Advantage program. I have posted excerpts but it’s always best to read the rule in its entirety. If the MA plan issues a denial on the basis of medical necessity, the decision must be reviewed “by a physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the services at issue.”  I see this as a problem in wound care since there is no recognized specialty. Undersea and Hyperbaric Medicine IS a recognized medical subspecialty so that might help patients obtain necessary HBOT treatments. The rule goes into effect Jan 1, 2024.  Whether this will make MA less of a Medicare DIS-advantage is yet to be seen.

Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly

A Rule by the Centers for Medicare & Medicaid Services on 04/12/2023

Annual Review of Utilization Management Tools (§§ 422.101, 422.112, 422.137, 422.138, and 422.202)

  1. Review of Medical Necessity Decisions by a Physician or Other Health Care Professional With Expertise in the Field of Medicine Appropriate to the Requested Service and Technical Correction to Effectuation Requirements for Standard Payment Reconsiderations (§§ 422.566, 422.590, and 422.629)

We proposed to revise §§ 422.566(d) and 422.629(k)(3) to state if the MA organization or applicable integrated plan expects to issue a partially or fully adverse medical necessity . . . decision based on the initial review of the request, the organization determination must be reviewed by a physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the services at issue, including knowledge of Medicare coverage criteria, before the MA organization issues the organization determination decision.

This is the same standard of review with respect to expertise that applies to physician review of reconsiderations at § 422.590(h)(2). The rule at § 422.590(h)(2) interprets and implements the requirement in section 1852(g)(2)(B) of the Act that any reconsideration that relates to a determination to deny coverage based on a lack of medical necessity be made only by “a physician with appropriate expertise in the field of medicine which necessitates treatment” to mean a physician with an expertise in the field of medicine that is appropriate for the covered services at issue. As stated in the proposed rule, we believe it is appropriate to adopt this standard for the medical necessity review of organization determinations by physicians and other appropriate health professionals in §§ 422.566(d) and 422.629(k)(3) where the plan expects to issue an adverse decision.

Caroline Fife, MD

Dr. Fife is Co-Founder and Chief Medical Officer of Intellicure, Executive Director of the US Wound Registry, and Editor of Today’s Wound Clinic.

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