On November 26, 2024, the Centers for Medicare and Medicaid Services (CMS) issued the Medicare Contract Year 2026 Proposed Rule, seeking to improve upon prior authorization policies established by the Medicare Contract Year 2024 final rule. The proposed rule seeks to establish guardrails for the use of artificial intelligence in coverage decisions, define “internal coverage criteria” so that its interpretation is uniform across all Medicare Advantage (MA) organizations, and disaggregate claims/service data collected for the MA annual health equity analysis. ASTRO submitted comments in support of these proposed provisions.

By January 1, 2026, CMS is proposing the following:

• MA organizations must publicly display on the organization's website a list of all Medicare items and services that involve the use of internal coverage criteria when making medical necessity decisions.
• The internal coverage criteria web page must be displayed in a prominent manner and clearly identified in the footer of the MA plan’s website. The web page must be easily available to the public, without barriers, including but not limited to ensuring the information is available free of charge, without having to establish a user account or password.

CMS has also clarified that information contained in Local Coverage Articles (LCA) may not be used as internal coverage criteria when making coverage decisions on basic benefits, citing that the Local Coverage Determination (LCD) provides the criteria that must be satisfied for Medicare coverage; not the LCA.

By disaggregating the claims service data collected, it is the intention that CMS and MA plans may more readily identify trends related to the use of prior authorization and, therefore, be able to more fully identify and address the impact of prior authorization on enrollees. The proposed metrics for the annual health equity analysis on the use of prior authorization include the following:

• The percentage of standard prior authorization requests that were approved, reported by each covered item and service.
• The percentage of standard prior authorization requests that were denied, reported by each covered item and service.
• The percentage of standard prior authorization requests that were approved after appeal, reported by each covered item and service.
• The average and median time that elapsed between the submission of a request and a determination by the MA plan, for standard prior authorizations, reported by each covered item and service.

CMS believes that collecting detailed information from initial coverage decisions and plan-level appeals, such as decision rationales for items, services or diagnosis codes, will provide a better understanding of how MA plans apply utilization management and prior authorization practices, among many other issues.