CMS Issues Guidance on AI Use for Determining Medicare Advantage Care

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On Feb. 6, 2024, the Centers for Medicare and Medicaid Services submitted a notice to Medicare Advantage care plans governing the use of artificial intelligence and algorithmic models in making care determinations for Medicare Advantage beneficiaries. The notice indicated that Medicare Advantage payers could not deny necessary care to patients based exclusively on AI tool recommendation, especially if the recommendation conflicts with physician recommendations or the individual problem list and medical history of the patient.

The notice was published months after UnitedHealth was sued for allegedly using faulty AI to deny care to Medicare Advantage patients.

The notice clarified that an AI tool can be used to assist Medicare Advantage plans in making coverage determinations, but the AI must comply with all applicable rules for how coverage determinations are made. Individual patient circumstances are the key factor. AI that makes a coverage determination based on a population data set instead of the individual patient's medical history, the physician’s recommendations or clinical notes would not be compliant.

For services to be denied or taken away, the notice clarified that the patient must no longer meet the level of care requirements based on medical history, physician recommendation or clinical notes. The notice also indicated that an AI recommendation alone can’t be used to deny admission or downgrade to an observation stay.

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