In Medicare Advantage, AI can't issue medical necessity denials alone
A physician or other appropriate health care professional must review each denial first. Cite that rule, 42 CFR 422.566(d) in the Code of Federal Regulations.
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Your patient's Medicare Advantage plan denied a prior authorization request for transcranial magnetic stimulation (TMS) within hours. The denial notice says TMS isn't medically necessary. Ask the plan to reconsider.
Rules the plan must follow
Two rules in the Code of Federal Regulations (CFR) apply to your patient's denial: 42 CFR 422.566(d) and 42 CFR 422.101(c)(1)(i). Under the second rule, the decision must rest on your patient's medical history, physician recommendations, and clinical notes. Cite both rules in your letter.
I request a standard reconsideration of the denial of transcranial magnetic stimulation for my patient. I have told my patient about this request.
42 CFR 422.566(d) requires a physician or other appropriate health care professional to review a medical necessity denial before it is issued. Please name the reviewer and the reviewer's specialty.
42 CFR 422.101(c)(1)(i) requires the decision to rest on the patient's medical history, physician recommendations, and clinical notes. Please list the records you reviewed.
The full record is attached. Please approve the request.
Federal Medicare Advantage rules at 42 CFR 422.566(d) and 422.101(c)(1)(i). Citing both asks the plan to name its reviewer and the records behind the denial.
If you're the treating physician, you can file once you've told the patient, per 42 CFR 422.578. Other prescribers can file as the patient's appointed representative, per 42 CFR 422.561. Send the letter as your written request. If the plan has its own reconsideration form, fill it in and attach the letter.
When the plan must receive your request
Count the 60-day filing period from 5 calendar days after the date on the denial notice, per 42 CFR 422.582(b). That's when the rule presumes the notice arrived. Your request counts as filed when the plan receives it.
What to attach
- 1The denial notice
- 2Your notes on the patient's history, diagnoses, and symptoms
- 3Your recommendation and the treatments already tried
- 4Any scores or criteria the plan's policy asks for
Four items for the reconsideration of a medical necessity denial. The plan must base its decision on the patient's records under 42 CFR 422.101(c)(1)(i), so each item gives the reviewer a record to check.
Send the four items. Put them in one file with a contents list, so the reviewer can find each page.
What the plan must do next
The plan has 30 calendar days. Count them from the day the plan receives your request, per 42 CFR 422.590. The plan can add up to 14 calendar days in only three cases and must send your patient a written notice of the reasons. Ask your patient for that notice.
- Your patient asks for the extension.
- The plan needs evidence from a noncontract provider that may change the denial, and the extension serves your patient.
- Extraordinary, exigent, or other non-routine circumstances justify the extension, and it serves your patient.
By the deadline, the plan must approve the request or send the case to an independent reviewer under contract with Medicare. The plan's decision must come from a physician with expertise in the field that covers TMS, and nobody involved in the first denial can conduct the reconsideration.
The Export chart action in JotPsych builds one PDF from the notes and documents you select, with a contents list.
Book 15 minutes- 42 CFR 422.566, organization determinations, paragraph (d).
- 42 CFR 422.101, requirements relating to basic benefits, paragraph (c)(1)(i).
- 42 CFR 422.578, right to a reconsideration.
- 42 CFR 422.582, request for a standard reconsideration.
- 42 CFR 422.561, definitions.
- 42 CFR 422.590, timeframes and responsibility for reconsiderations, paragraphs (a), (f), and (h).