An algorithm cannot be the decision-maker
Medicare Advantage plans must base medical-necessity decisions on the individual patient and may use software only as a tool, California requires a licensed physician to make any medical-necessity denial, and every ERISA and ACA plan must disclose the criteria it used. The lever is a written question: what tool, which criteria, which human.
When it applies
- Denials that arrive fast, generic and identical across patients (post-acute care, imaging, therapy caps)
- Medicare Advantage (42 CFR 422.101(c)(1)(i)); California-regulated plans (SB 1120); all ERISA and ACA plans via disclosure rules
Where it does not
- Nothing forbids software as such; the duty is an individualised determination by a qualified person, with the basis disclosed
The sentence to put in the appeal
“Please identify any automated decision tool, algorithm or predictive model used in this determination, the person who reviewed its output and their qualifications, and the criteria applied. Under [42 CFR 422.101(c)(1)(i) / California Health & Safety Code as amended by SB 1120 / 29 CFR 2560.503-1(h)(2)(iii)], the decision must rest on my individual medical circumstances as determined by a qualified reviewer, and the basis must be disclosed on request.”
Replace the bracketed parts with your facts. Cite the regulation exactly as written; quote the plan’s own wording next to it.
How to use it
- Step 1
Ask in the claim-file request
The question about tools belongs beside the request for criteria and reviewer identity.
- Step 2
Put the individual facts in front of a human
A letter of medical necessity answering the criteria, plus a peer-to-peer request, forces a clinician to engage with the specific record.
- Step 3
Complain to the regulator
CMS (for Medicare Advantage) and state insurance departments track these complaints; a regulator inquiry often gets the file a second look.
Worked example
A post-acute stay was cut off on day 14 with a letter identical to others the facility had seen. The appeal asked what tool produced the date; the plan could not point to an individual review and reinstated coverage pending a physician reconsideration.
Illustrative composite; details vary by plan and record. Outcomes are not guaranteed.
Go deeper
Sources
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