Medicare Advantage cannot use stricter criteria than Medicare
Since 2024, a Medicare Advantage plan must cover what Original Medicare covers under the same coverage rules, may use its own internal criteria only where Medicare's rules are not fully established, must make those criteria public with their evidence, and must decide medical necessity on the individual's circumstances. A denial that rests on a proprietary guideline where a national or local coverage determination exists is out of bounds.
When it applies
- Medicare Advantage denials of hospital admission, skilled nursing, home health, rehab, imaging, procedures
- Denials citing MCG, InterQual or a plan's own policy when Medicare has an NCD, LCD or statutory rule on the service
- Denials produced by an algorithm without individual review
Where it does not
- Original Medicare (the rules apply directly there)
- Supplemental benefits the plan adds beyond Medicare
The sentence to put in the appeal
“Under 42 CFR 422.101(b)(6) and (c)(1), the plan must apply Medicare's coverage criteria for this service and may not deny on the basis of internal criteria that are more restrictive than [the applicable NCD/LCD/Medicare rule]. The determination must be based on my individual medical history and the treating physician's recommendation, not solely on an algorithm or a generic guideline. Please identify the Medicare coverage rule applied and, if internal criteria were used, the publicly available evidence supporting them.”
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
Find the Medicare rule
Search the Medicare Coverage Database for an NCD or LCD on the service; for inpatient stays cite the two-midnight benchmark; for skilled care cite the maintenance standard.
- Step 2
Name the guideline the plan used
If the letter says MCG or InterQual, quote it, then put the Medicare rule beside it.
- Step 3
Request an expedited reconsideration
Pre-service and continuing-care denials qualify for a 72-hour decision when delay could seriously jeopardise health. An upheld reconsideration goes automatically to the Independent Review Entity.
Worked example
A skilled-nursing admission was denied under a proprietary length-of-stay guideline. The appeal cited 422.101(b)(6) and the Medicare SNF coverage rule, attached the hospital's discharge order, and the plan reversed at reconsideration. HHS-OIG found that plans reversed 95% of appealed SNF admission denials in its 2026 review.
Illustrative composite; details vary by plan and record. Outcomes are not guaranteed.
Go deeper
Sources
- 42 CFR 422.101, Medicare Advantage requirements relating to basic benefits (coverage criteria)
- CMS-4201-F, CY2024 Medicare Advantage final rule (coverage criteria, utilization management)
- CMS, FAQs on coverage criteria and utilization management (February 2024)
- HHS-OIG, Medicare Advantage organizations overturned nearly all appealed SNF admission denials (2026)
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