Was This Medicare Advantage Denial Allowed to Use These Criteria?
Whether a Medicare Advantage denial followed the process rules: whose criteria, public evidence, reviewer, 90-day transition.
Open the tool → Runs in your browser. Data leaves only if you deliberately send a problem report from the interactive tool.
Example
- Basic or supplemental benefit
- A service Original Medicare covers (a basic benefit)
- Reason the denial gave
- Not medically necessary (or similar wording)
- Whose criteria the denial cites
- The plan's own criteria (or a vendor's, like InterQual or MCG)
- Whether Medicare criteria are fully established
- Yes: an NCD, LCD or Medicare rule sets the criteria for this service
Result: A process requirement was not met: 42 CFR 422.101(b)(6) and (c)(1)(i)(A). That is a ground for reconsideration; it does not decide medical necessity.
The tool opens with these values already filled in. Replace them with your own.
What you enter
- Basic or supplemental benefit
- Reason the denial gave
- Whose criteria the denial cites
- Whether Medicare criteria are fully established
- Internal criteria posted publicly
- Evidence summary posted publicly
- Who reviewed the denial
- Ongoing course of treatment
- Days from enrollment to the denial
How this is calculated
Citation
42 CFR 422.101(b)-(c) (internal coverage criteria, (b)(6)), 422.566(d) (who reviews a denial) and 422.112(b)(8) (course of treatment; 90-day transition), as amended by CMS-4201-F (2023). Read the sources: 42 CFR 422.101 ↗, 42 CFR 422.566 ↗, 42 CFR 422.112 ↗
A reference and educational tool. Not medical, legal, or financial advice, and not a substitute for clinician judgment.