“We follow Medicare.”

It’s a common answer DME suppliers get when trying to understand why a Medicare Advantage Plan (MAP) denied a claim.

It’s a common answer, but not always an accurate one.

CMS, however, has been active in pinning MAPs down to follow Medicare criteria where it exists. But what if it does not?

Next Episode: Thursday, June 20, 2024

Final Rule CMS-4201-F, effective since January 1, 2024, includes requirements for MAPs with regards to coverage criteria for basic benefits. The general rule is that MAPs are bound by Medicare’s established coverage criteria. They cannot enforce any coverage requirements that are more restrictive than Medicare Fee-For-Service (FFS).

CMS allows MAPs to create their own coverage policy only in cases where Medicare offers none.

Requirements for Enforceable Internal Coverage Criteria

In FAQs published in February, CMS elaborated on the requirements MAPs must meet to create their own enforceable coverage criteria. FAQ #1 asks:

When can MAPs use internal coverage criteria to make medical necessity decisions?

In response, CMS writes:

“When FFS coverage criteria are not fully established … MAPs can create publicly accessible internal coverage criteria based on current evidence in widely used treatment guidelines or clinical literature [emphasis added].”

There are three important phrases in the answer:

  1. Fully established,
  2. Publicly accessible, and
  3. Based on current evidence in widely used treatment guidelines or clinical literature.

The Meaning of “Fully Established”

CMS was very clear in CMS-4201-F. MAPs cannot create internal guidelines that are more restrictive than existing Medicare FFS coverage criteria. If, for example, Medicare has an NCD, but not LCD or policy article, MAPs cannot create internal policy that further restricts the coverage offered by the NCD. This limits MAPs to developing coverage guidelines for novel products and services that meet the definition of DMEPOS, but have no NCD or LCD (like wrist braces and other non-codified products).

The Meaning of “Publicly Accessible”

CMS addresses this question directly in FAQ #3:

“‘Publicly accessible’ means available to all in the public (not just enrollees or network suppliers). It must also be posted on a website that is not behind a paywall or require subscription to access.”

These words, perhaps more than any other written on the topic of MAP compliance, address the policy shenanigans that have frustrated DME suppliers for so long. Specifically, MAPs seem to make medical necessity decisions based on policies they create after the fact … polices only they can access until it suits them, without regard to suppliers or beneficiaries.

By explicitly directing MAPs to make their medical necessity policies available to the general public, CMS insists relevant policy is easily available to anyone – supplier or beneficiary – before the public commits to doing business with the MAP.

The Meaning of “Based on Current Evidence …”

In the FAQs, CMS describes the types of sources MAPs must rely on when crafting their own coverage criteria. They give the following examples:

  • Large, randomized controlled trials,
  • Prospective cohort studies with clear results,
  • Evidence published in a peer-reviewed journal … and specifically designed to answer the relevant clinical question, or
  • Large systematic reviews or meta-analyses summarizing the literature of the specific clinical question.

These are the types of sources you will find in a Google Scholar search. A memo from Ralph in accounting doesn’t qualify.

Overall, I think CMS’s continued commitment to aligning MAP coverage with Medicare FFS is evidenced by the clarity of the FAQs. In cases where MAPs make decisions not based on Medicare, suppliers will be able to hold them accountable to specific criteria that, if not met, will be very powerful evidence for appeal.


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