U.S. Department of Health and Human Services
Office of Inspector General
Some Medicare Advantage
Organization Denials of Prior
Authorization Requests Raise
Concerns About Beneficiary
Access to Medically Necessary
Care
Christi A. Grimm
Inspector General
April2022,OEI-09-18-00260 UU..SS..DDeepparatrmtmenetnotfHoefaHltehaalnthd HanumdaHnuSmeravinceSservices
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April 2022, OEI-09-18-00260
April2022, OEI-09-18-00260
Some Medicare Advantage Organization
Why OIG Did This Review
Acentralconcernaboutthe Denials of Prior Authorization Requests
capitatedpaymentmodelusedin
Raise Concerns About Beneficiary Access to
MedicareAdvantageisthe
potentialincentiveforMedicare
Medically Necessary Care
AdvantageOrganizations(MAOs)
todenybeneficiaryaccessto
What OIG Found
servicesanddenypaymentsto Key Takeaway
Ourcasefilereviewsdetermined
providersinanattempttoincrease
MAOsdeniedprior thatMAOssometimesdelayedor
profits. AlthoughMAOsapprove
authorizationandpayment deniedMedicareAdvantage
thevastmajorityofrequestsfor
requeststhatmetMedicare beneficiariesaccesstoservices,
servicesandpayment,theyissue
coveragerulesby: eventhoughtherequestsmet
millionsofdenialseachyear,and
CMSsannualauditsofMAOshave  usingMAOclinicalcriteria Medicarecoveragerules. MAOs
highlightedwidespreadand thatarenotcontainedin alsodeniedpaymentstoproviders
persistentproblemsrelatedto Medicarecoveragerules; forsomeservicesthatmetboth
inappropriatedenialsofservices  requestingunnecessary MedicarecoveragerulesandMAO
billingrules. Denyingrequeststhat
andpayment. Asenrollmentin documentation;and
meetMedicarecoveragerulesmay
MedicareAdvantagecontinuesto  makingmanualreview
preventordelaybeneficiariesfrom
grow,MAOsplayanincreasingly errorsandsystemerrors.
receivingmedicallynecessarycare
criticalroleinensuringthat
andcanburdenproviders.
Medicarebeneficiarieshaveaccess
Althoughsomeofthedenialsthat
tomedicallynecessarycovered
wereviewedwereultimatelyreversedbytheMAOs,avoidabledelaysand
servicesandthatprovidersare
extrastepscreatefrictionintheprogramandmaycreatean
reimbursedappropriately.
administrativeburdenforbeneficiaries,providers,andMAOs. Examples
How OIG Did This Review ofhealthcareservicesinvolvedindenialsthatmetMedicarecoverage
Weselectedastratifiedrandom rulesincludedadvancedimagingservices(e.g.,MRIs)andstaysinpost-
sampleof250denialsofprior acutefacilities(e.g.,inpatientrehabilitationfacilities).
authorizationrequestsand
250paymentdenialsissuedby Priorauthorizationrequests. Wefoundthatamongtheprior
15ofthelargestMAOsduring authorizationrequeststhatMAOsdenied,13percentmetMedicare
June17,2019. Healthcarecoding coveragerulesinotherwords,theseserviceslikelywouldhavebeen
expertsreviewedcasefilesforall approvedforthesebeneficiariesunderoriginalMedicare(alsoknownas
cases,andphysicianreviewers Medicarefee-for-service). Weidentifiedtwocommoncausesofthese
examinedmedicalrecordsfor denials. First,MAOsusedclinicalcriteriathatarenotcontainedin
asubsetofcases. Fromthese Medicarecoveragerules(e.g.,requiringanx-raybeforeapprovingmore
results,weestimatedtheratesat advancedimaging),whichledthemtodenyrequestsforservicesthatour
whichMAOsdeniedprior physicianreviewersdeterminedweremedicallynecessary. Althoughour
authorizationandpayment reviewdeterminedthattherequestsinthesecasesdidmeetMedicare
requeststhatmetMedicare coveragerules,CMSguidanceisnotsufficientlydetailedtodetermine
coveragerulesandMAObilling whetherMAOsmaydenyauthorizationbasedoninternalMAOclinical
rules. Wealsoexaminedthe criteriathatgobeyondMedicarecoveragerules.
reasonsforthesedenialsandthe
typesofservicesassociatedwith
thesedenialsinoursample. Second,MAOsindicatedthatsomepriorauthorizationrequestsdidnot
haveenoughdocumentationtosupportapproval,yetourreviewers
foundthatthebeneficiarymedicalrecordsalreadyinthecasefilewere
sufficienttosupportthemedicalnecessityoftheservices.
Paymentrequests. Wefoundthatamongthepaymentrequeststhat
MAOsdenied,18percentmetMedicarecoveragerulesandMAObilling
rules. Mostofthesepaymentdenialsinoursamplewerecausedby
humanerrorduringmanualclaims-processingreviews(e.g.,overlooking
adocument)andsystemprocessingerrors(e.g.,theMAOssystemwas
notprogrammedorupdatedcorrectly).
WealsofoundthatMAOsreversedsomeofthedeniedprior
authorizationandpaymentrequeststhatmetMedicarecoveragerules
andMAObillingrules. Oftenthereversalsoccurredwhenabeneficiary
orproviderappealedordisputedthedenial,andinsomecasesMAOs
identifiedtheirownerrors.
What OIG Recommends
OurfindingsaboutthecircumstancesunderwhichMAOsdenied
requeststhatmetMedicarecoveragerulesandMAObillingrulesprovide
anopportunityforimprovementtoensurethatMedicareAdvantage
beneficiarieshavetimelyaccesstoallnecessaryhealthcareservices,and
thatprovidersarepaidappropriately. Therefore,werecommendthat
CMS:
(1)issuenewguidanceontheappropriateuseofMAOclinicalcriteriain
medicalnecessityreviews;
(2)updateitsauditprotocolstoaddresstheissuesidentifiedinthis
report,suchasMAOuseofclinicalcriteriaand/orexaminingparticular
servicetypes;and
(3)directMAOstotakestepstoidentifyandaddressvulnerabilitiesthat
canleadtomanualreviewerrorsandsystemerrors.
CMSconcurredwithallthreerecommendations. TABLE OF CONTENTS
BACKGROUND 1
Methodology 5
FINDINGS 9
Thirteen percent ofprior authorization denials were for service requests that met Medicare 9
coverage rules, likely preventing or delaying medically necessary care for Medicare Advantage
beneficiaries
Eighteen percent ofpayment denials were for claims that met Medicare coverage rules and 12
MAO billing rules, which delayed or prevented payments for services that providers had
already delivered
Imaging services, stays in post-acute facilities, and injections were three prominent service 14
types among the denials that met Medicare coverage rules
MAOs reversed some initialprior authorization denials and payment denials for requests that 18
met Medicare coverage rules and MAO billing rules
CONCLUSION AND RECOMMENDATIONS FOR CMS 20
Issue new guidance on the appropriate use of MAO clinicalcriteriain medicalnecessity 20
reviews
Update its auditprotocols to address the issues identified in this report, such as MAO use of 21
clinicalcriteria, and/or examine particular service types
Direct MAOs to take additionalsteps to identify and address vulnerabilities that can lead to 21
manualreview errors and system errors
AGENCY COMMENTS AND OIG RESPONSE 23
DETAILED METHODOLOGY 24
APPENDICES 31
A. Point Estimates and Confidence Intervals for Denials of Prior Authorization and Payment 31
Requests That Met Medicare Coverage Rules, Issued by 15 Selected MAOs During June 17,
2019
B. Detailed Descriptions of Denials for Requests That Met Medicare Coverage Rules 32
C. Characteristics of Sampled MAOs 52
D. Agency Comments 53
ACKNOWLEDGMENTS AND CONTACT 56
ABOUT THE OFFICE OF INSPECTOR GENERAL 57 BACKGROUND
Objectives
1. Todetermine the extent to which selected Medicare Advantage
Organizations (MAOs)denied prior authorization requests for services
that met Medicare coverage rules, and to examine why these denials
occurred.
2. Todetermine the extent to which the selected MAOs denied payment
requests that met Medicare coverage rules and MAO billing rules, and
to examine why these denials occurred.
3. Todescribe the types ofhealth care services involved in denials of
services andpayments that met Medicare coverage rules and MAO
billing rules.
Enrollmentin Medicare Advantage (alsoknown as Medicare Part C)has continued to
increase over the last decade (see Exhibit1). Of all Medicare beneficiaries in 2021,
42 percent (26.4 million) were enrolled in a Medicare Advantage plan. The
CongressionalBudget Office projects that the share ofall Medicare beneficiaries
enrolled in Medicare Advantage plans willrise to about 51 percent by 2030.1
Exhibit 1: Total Medicare Advantage enrollment has more than doubled since
2011; Medicare Advantage covered 26.4 million beneficiaries in 2021.
Source:KaiserFamilyFoundation,MedicareAdvantagein2021:EnrollmentUpdateandKeyTrends,June2021.
1KaiserFamilyFoundation,MedicareAdvantagein2021:EnrollmentUpdateandKeyTrends,June2021.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Background|1 The Medicare program covers a wide range ofhealth care services when they are
medically necessary for beneficiaries. Medicare Advantage is designed to cover the
same services as originalMedicare (also known as fee-for-service Medicare), but in
Medicare Advantage, MAOs2 are also responsible for the coordination ofcare for
beneficiaries enrolled in their plans.3,4 The goal of coordinated care is to provide
efficient, high-quality care that improves patient health outcomes while also
managing program costs. To manage care for beneficiaries and to help controlcosts,
MAOs may impose additionalrequirements, such as requiring that beneficiaries use
only in-network providers for certain health care services; requiring prior
authorization before certain services can be provided; or requiring referrals for
specialty care services.
Although MAOs approve the vastmajority ofprior authorization requests and
provider payment requests, MAOs also deny millions ofrequests each year. A central
concern about capitated payment modelsincluding the modelused in Medicare
Advantageis the potentialincentive for insurers to deny access to services and
paymentin an attempt to increase profits.5 The Centers for Medicare & Medicaid
Services (CMSs) annualaudits of MAOs have highlighted widespread and persistent
problems related to inappropriate denials ofservices and payment.6 This report
focuses on the subset ofprior authorization requests and provider payment requests
that MAOs denied. We examined these denied requests to assess the extentto which
the denied requests metMedicare coverage rules, and thus would likely have been
approved in original Medicare.
Medicare Coverage Rules
MAOs must follow Medicare coverage rules, which specify what items and services are
covered and under what circumstances. BecauseMAOs must provide beneficiaries
with allbasic benefits covered underoriginalMedicare, they may not impose
limitationssuch as waiting periods or exclusions from coverage due to pre-existing
conditionsthat are not present in original Medicare.7 Medicare coverage rules are
outlined in nationalcoverage determinations (NCDs); localcoverage determinations
(LCDs)in the geographic area in which the MAO operates; the Medicare BenefitPolicy
Manual; the Medicare Managed Care Manual; legislative changes in benefits applied
2Forthepurposesofthisreport,weuseMAOtomeanaparentcompanythatoperatesoneormore
MedicareAdvantagecontracts.
3Ataminimum,MAOsmustcoverthesameservicesasinoriginalMedicare,althoughtheymayalso
offersupplementalbenefits. 42CFR422.101(a)and(b);422.102. MAOsarenotresponsibleforpaying
hospicecarecostsforbeneficiaries;thesecostsarepaidbyoriginalMedicare.
4CMS,MedicareManagedCareManual,ch.5,sec.10.
5Incapitatedpaymentmodels,insurancecompaniesorprovidersreceiveafixedamountofmoneyper
patientregardlessofthenumberofservicesprovidedtothepatient.
6OIG,MedicareAdvantageAppealOutcomesandAuditFindingsRaiseConcernsAboutServiceand
PaymentDenials,September2018.
7CMS,MedicareManagedCareManual,ch.4,sec.10.2.p.7.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Background|2 through notice-and-comment rulemaking, and other coverage guidelines and
instructions issued by CMS.8 Coverage rules can include administrative requirements
(e.g., requiring that a specific form be completed)and clinical requirements (e.g.,
outlining the types ofcancer for which Medicare willcover chemotherapy).9
MAO Clinical Criteria and Billing Rules
Although MAOs must follow Medicare coverage rules, they are also permitted to use
additionalclinicalcriteria that were not developed by Medicare when they are
determining whether to authorize or pay for a service, as long as such criteriaare no
more restrictive than original Medicares nationaland local coverage policies.10 For
example, MAOs may develop and use their own internalclinicalcriteria or use
commercially available clinicalguidelines developed by private health care
management companies. (This report uses the term MAO clinicalcriteria to refer to
any clinicalcriteriathat MAOs adopt.) MAO clinicalcriteria are typically more detailed
than Medicare coverage rules and are intended to assist with clinicaldecision making.
MAOs must provide beneficiaries with an annual Evidence ofCoverage document that
gives an overview of coverage requirements and beneficiary cost-sharing.11
MAOs may create their own billing and paymentproceduresas long as allproviders
are paid accurately, timely, and with an audittrail.12 Providers must follow MAO
billing rules, such as those outlined in provider contracts (e.g.,payment requests must
be filed within specific timeframes). MAOs may also require that providers adhere to
Medicare billing rules, such as the Medicare Claims Processing Manual.
MAO Coverage Determination Process
MAOs must establish procedures for making decisionsalso called coverage
determinationsabout whether to approve or deny requests.13 MAOs issue coverage
determinations for two types ofrequests: (1)prior authorization requests, which are
requests for the MAO to preapprovea service or item before the beneficiary receives
8CMS,MedicareManagedCareManual,ch.4,secs.90.2and90.3. NationalCoverageDeterminationsare
DepartmentofHealthandHumanServicesdeterminationsonwhetheraparticularitemorserviceis
coveredunderMedicare. Localcoveragedeterminationsarewrittencoveragedecisionsoflocal
MedicareAdministrativeContractorswithjurisdictionforclaimsinaparticulargeographicarea.MAOs
areresponsibleformonitoringCMSsnationalcoveragedeterminationsandpublicationstoensurethat
theyarecomplyingwithallMedicarecoveragerules.
9IfMedicarecoveragerulesdonotexistforaspecificservice,thenMAOsmustdeterminewhetherthe
requestedserviceisreasonableandnecessaryforthebeneficiaryandmayusethecoveragepoliciesof
otherMAOsintheirserviceareaorotherauthoritativeevidencesuchaspeer-reviewedclinicalstudies.
SocialSecurityAct1862(a)(1)(A). CMS,MedicareManagedCareManual,ch.4,sec.90.5.
10CMS,MedicareManagedCareManual,ch.4,sec.10.16.
1142CFR422.111.
12CMS,MedicareManagedCareManual,ch.4,sec.10.2.
1342CFR422.566;CMS,PartsC&DEnrolleeGrievances,Organization/CoverageDeterminations,and
AppealsGuidance,sec.10.4.4.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Background|3 it; and (2)payment requests from a provider for a service already delivered to the
beneficiary. CMSrequires that MAOs have a medicaldirector whois responsible for
ensuring theclinical accuracy ofall coverage determinations involving an assessment
ofmedical necessity.14
Prior authorization requests. MAOs can require that providers receive authorization
for certain services before the MAO willprovide coverage and payment.15 Prior
authorization is a utilization managementtool that MAOs can use to controlcosts
and ensure the most cost-effective, clinically appropriate treatment is offered to
beneficiaries. Prior authorization requests are reviewed by MAO clinical staff to
determine whether itemsand services are medically necessaryand reasonable for the
beneficiary, and whether they meetMedicare and MAO coverage rules. For context,
in 2018, MAOs denied 1.5 million prior authorization requests overall(5 percent ofall
prior authorization requests)in the Medicare Advantage program.16,17
Payment requests. Providers who are paid on a fee-for-service basis by the MAO
submitpayment requests to receive reimbursement for services that the providers
have already delivered to beneficiaries. As with the MAOs decision on a prior
authorization request, the MAOs decision to approve or deny the payment request
must be consistent with applicable rules for Medicare coverage and MAO billing. For
context, in 2018, MAOs denied 56.2million payment requests overall (9.5 percent of
allpayment requests) in the Medicare Advantage program.18
Appeals. When an MAO denies a prior authorization request, the beneficiary may
elect not to receive the service; the beneficiary may electto receive the service and
pay for it outofpocket; or the beneficiary or the beneficiarys representative can file
an appealof the denial with the MAO.19 Similarly, when MAOs deny payment
requests, providers can dispute or appealthe denial. Providers whoenter into a
contract with an MAO (i.e., in-network providers)can file a payment dispute, which is
processed and resolved according to the provisions in the MAOs provider manualor
other documentthat delineates the MAO-specific dispute process. Providers who do
not have a contract with an MAO can file an appealofthe denial.
1442CFR422.562;CMS,MedicareManagedCareManual,ch.4,sec.10.16.
15CMS,MedicareManagedCareManual,Chapter,ch.4,sec.110.1.1.
16CMS,2018PartCReportingRequirementsData,accessedonJune3,2021. In2019,CMSchanged
MAOdatareportingrequirementstoexcludethereportingofpaymentrequestsfromcontracted
providers. Becauseouranalysisincludespaymentrequestsfromcontractedproviders,weanalyzed
CMSsdatafrom2018togivecontextonoverallMAOdenialrates.
17In2018,MAOsoverturned86,193priorauthorizationdenialsfollowinganappeal.
18CMS,2018PartCReportingRequirementsData,accessedonJune3,2021. In2018,MAOsoverturned
258,524paymentdenialsfollowinganappeal.
19CMS,PartsC&DEnrolleeGrievances,Organization/CoverageDeterminations,andAppealsGuidance
(cms.gov),p.15. Individualswhorepresentbeneficiariesmayeitherbeappointedorauthorizedtoacton
behalfofthebeneficiaryindealingwithanyofthelevelsoftheappealsprocess.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Background|4 CMS oversight
CMSuses severaltools to oversee the performance ofMAOs and ensure that
beneficiaries have accessto necessary care. CMS assigns an account manager and
lead caseworker for each MAO contract. Account managers monitor complaints from
beneficiaries and work with MAOs to promote compliance with Medicare program
requirements.
Each year, CMS audits a sample of MAOs to measure an MAOs compliance with the
terms ofits contract with CMS. During the audits, CMS evaluates MAO compliance
with requirements associated with beneficiaries access to covered Medicare services,
access to drugs, and other beneficiary protections required by Medicare.20 CMS
requires MAOs to implement corrective action plans to address any auditviolations
and to demonstrate that they have substantially corrected deficiencies before the
auditis officially closed. CMSmay impose civil money penalties and sanctions for
serious violations identified through audits.
Prior OIG work on denials in Medicare Advantage
In a September 2018 report, wefound that when beneficiaries and providers appealed
denied requests in Medicare Advantage during 20142016,MAOs overturned about
75 percent oftheir own prior authorization denials and payment denials.21 We also
found that CMS cited more than half ofaudited MAO contracts in 2015 for
inappropriately denying prior authorization and payment requests. We
recommended that CMS address persistent problems related to denials identified in
its audits. CMS responded that ithad increased the penalties for MAO violations that
prevent beneficiaries from accessingmedically necessary services. We also
recommended that CMS enhance its oversightof MAO appeals data and provide
beneficiaries with clear, easily accessible information about serious violations by
MAOs. As ofMarch 2022, CMS had not yet implemented these recommendations.
Methodology
Scope
Using arandom sample ofdenials from the 1-week period ofJune 17, 2019, this
report estimates the rate at which 15 ofthe largest MAOs denied prior authorization
and paymentrequests that met Medicare coverage rules. Italsodescribes the causes
20CMSauditsMAOcomplianceinseveralprogramareas,includingMedicareAdvantage(PartC)
coveragedeterminations,appeals,andgrievances. CMSsannualauditenforcementreportsareavailable
athttps://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-
Audits/ProgramAudits.html. Duringtheaudits,CMSreviewsasampleofMAOdenialstodetermine
whethertheywereappropriate,butCMSdoesnotcalculatearateofinappropriatedenials.
21OIG,MedicareAdvantageAppealOutcomesandAuditFindingsRaiseConcernsAboutServiceand
PaymentDenials,September2018.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Background|5 and other issues associated with these denials; prominent service types among these
cases; and (when available)MAO-reported actualor estimated costs.
Sample Selection
We selected 15 ofthe largest MAOs by enrollment as the study population. These
MAOs accounted for nearly 80 percent ofbeneficiaries enrolled in Medicare
Advantage as ofJune 2019, ranging in size from about 165,000 to nearly 6 million
beneficiaries.
To compile a sampling frame, we collected a list ofallprior authorization denials and
paymentdenials that each selectedMAO issued during a 1-week period, June 17,
2019. We stratified the sample frame ofnearly 283,000 totaldenials by type of
request (prior authorization or payment)and MAO enrollment size. We then selected
a stratified random sample of500 denialcases, consisting of250 prior authorization
denials and 250 paymentdenials.
During our review, we identified 70 sampled cases that were ineligible for this study
(e.g., denials ofrequests for supplemental benefits that are not covered in original
Medicare)and excluded them from our analysis. This resulted in a finalsample of
430 cases.
See Detailed Methodology on page 24 for further information.
Case File Collection and Preliminary Screening
To conduct the case file reviews, we contracted with health care coding and billing
professionals with expertise in Medicare coverage rules and with physicians. (In this
report, we refer to the first group as health care coding experts.) Initially, the health
care coding experts checked whether a case was eligible for our sample. Then they
reviewed the case files ofthe 430 eligible cases for completeness and made additional
requests to the MAOs for missing records or information needed for case file reviews.
Case File Reviews
To design the case file review methodology, we consulted with the following: CMS;
the Medicare Advantage IndependentReview Entity contractor (which reviews
appeals that were upheld by MAOs); physicians;and health care coding experts. We
also reviewed CMSpolicy documents such as the Medicare Managed Care Manual.
The objective ofthe case file reviews was to determine whether the denied prior
authorization and payment requestsmet relevant Medicare coverage rules and, if
applicable, MAO billing rules. For our sample of 430 eligible cases, we conducted
reviews for administrative coverage only for 268 cases, and for the remaining 162
cases we conducted reviews for both administrative coverage and medical necessity.
Reviewers followed a structured protocolthat OIG developed in consultation with
health care coding experts and physicians.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Background|6 Administrative coverage reviews: Our health care coding experts determined
whether the prior authorization or paymentrequests met the Medicare coverage rules
and/or MAO billing rules that the MAO cited as support for its denialdecision. For
example, MAOs often cited NCDs and LCDs; the Medicare Managed Care Manual;
the beneficiarys Evidence ofCoverage Document; and other MAO billing rules.
Medical necessity reviews: Ifour health care coding experts assessed that denial
cases needed a medical necessity review to determine whether the request met
Medicare coverage rules,then the cases receivedan additionalclinicalreviewby a
physician. Following a structured OIG protocol, physicians used their clinical
judgment to determine whether the denied service was medically necessary for the
beneficiary using the medicalrecords and other clinical information available in the
case file. For any case for which the physician reviewer determined that the service
was medically necessary,or for which the physician reviewer wanted to consultwith
other physicians, we convened consensus calls among a panelofthree physicians to
discuss the case. The three-physician panelthen reached consensus regarding
whether a denied service was medically necessary for the beneficiary, based on clinical
information in the medicalrecords that the MAO had submitted to OIG. A health care
coding expert then reviewed these cases to determine whether the case met
administrative rules for Medicare coverage.
Analysis
We analyzed the results ofthe reviews by health care coding experts and the clinical
reviews by physicians, and we generated population estimates ofthe rates ofprior
authorization denials and payment denials for requests that met Medicare coverage
rules and MAO billing rules. We also generated population estimates for the rates at
which prior authorization denials and payment denials were issued for services that
met Medicare coverage rules and MAO billing rules, but werethen reversed by the
MAOs. See AppendixA on page 31 for point estimates, 95-percent confidence
intervals, and key statistics.
Limitations
The results ofthe case reviews were limited tothe documentation available in the
medicalrecords submitted by the MAOs at the time ofour review. Although we
followed up with MAOs tohelp ensure that they submitted all relevant records, we
were not able to verify whether additional information might have existed but was not
submitted. Further, thecase review results were subject to the interpretations and
clinical judgments ofthe health care coding experts and physician reviewers.
Because a significant number ofcases in the sample did not have cost data in their
records, we were not able to estimate the costs associated with denials, such as added
charges to Medicare beneficiaries or unpaid reimbursements to providers. When this
information was available, we indicated the cost associated with denials in our sample
that we determined met Medicare coverage rulesand MAO billing rules.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Background|7 Standards
We conducted this study in accordance with the Quality Standardsfor Inspection and
Evaluation issued by theCouncil ofthe Inspectors Generalon Integrity and Efficiency.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Background|8 FINDINGS
Thirteen percent of prior authorization denials were for service
requests that met Medicare coverage rules, likely preventing or
delaying medically necessary care for Medicare Advantage
beneficiaries
Ofthe 12,273 denials of requests for services (prior authorization denials) issued by
the 15 selected MAOs during the first week ofJune 2019, an estimated 13 percent
met Medicare coverage rules.22 In other words, these serviceslikely would have been
approved for these beneficiaries under original Medicare (also known as Medicare
fee-for-service). This projects to 1,631 prior authorization denials for requests that
met Medicare coverage rules for the selected MAOs during that week. For an annual
context, ifthese MAOs denied the same numberofprior authorization requests
(1,631)in each ofthe other 51 weeks of2019, they would have denied
84,812 beneficiary requests for services that met Medicare coverage rulesthat year.
MAO denials ofprior authorization requests for services thatmeet Medicare coverage
rules can create significant negative effects for Medicare Advantage beneficiaries.
These denials can delay or prevent beneficiary access to medically necessary care;
lead beneficiaries to pay out ofpocket for services that are covered by Medicare; or
create an administrative burden for beneficiaries or their providers who choose to
appealthe denial. These denials may be particularly harmfulfor beneficiaries who
cannot afford to pay for services directly and for critically illbeneficiaries whomay
suffer negative health consequencesfrom delayed or denied care.
MAOs denied prior authorization requests for services that were
medically necessary by applying MAO clinical criteria that are not
contained in Medicare coverage rules
For many of the denials ofprior authorization requests in our sample for services that
met Medicare coverage rules, MAOs denied the requests by applying MAO clinical
criteriathat are not required by Medicare. As shown in the examples below, we found
that in these cases MAOs used specific, mandatory requirements that resulted in the
denialofprior authorization requests for medically necessaryservices. In contrast,
original Medicare does not impose such specific requirements for covering the
procedures involved. (For more detailed descriptions of allprior authorization and
22Asstatedonpage4ofthisreport,in2018,MAOsdenied5percentofallpriorauthorizationrequests
intheMedicareAdvantageprogram.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Findings|9 paymentcases that met Medicare coverage rulesand MAO billing rules, see
Appendix B on page 32.)
Case D472: MAO restricted followup MRIs based on the size of the
beneficiarys lesion, a restriction that is not included in Medicare coverage
rules.
Eight months after a beneficiary was discovered to have an adrenallesion of1.5 cm in
size, an MAO denied a request for a followup MRI (estimated cost $300). The MAO
stated that the beneficiary would need to wait at least1 year for the followup MRI
because thesize ofthe lesion (less than 2 cm)was too smalltowarrant followup
before 1 year. However, our health care codingexperts determined that the
applicable NCD does not restrict the timing offollowup MRIs based on the size of
lesions. Furthermore, our physician panelstated that the documentation in the
original request demonstrated that the MRI was medically necessary to determine
whether the lesion seen on an earlier CT scan was malignant. (The MAO reversed its
original denialupon appeal. See case D472 in AppendixB for additional details.)
Case D460: MAO applied an ambulatory device limit that is not included in
Medicare coverage rules.
An MAO denied a request for a walker (estimated cost $112)for a 76-year-old
beneficiary with post-poliosyndrome. The MAO stated that, per its clinicalcriteria,
the beneficiary was not eligible to receive a walker because the beneficiary had
already received a cane within the past 5 years. The MAOs clinical criteriaconsidered
these devices to be the same or similar and limited beneficiaries to one such device
every 5 years. However, our health care codingexpert determined that the applicable
LCD for walkers does not include a 5-year restriction on more than one ambulatory
device. Further, our physician panel determined that the walker was medically
necessary given the beneficiarys history, risk of falling, and physicaltherapy notes.
These factors indicated that the beneficiary could not walksafely with only a cane.
(See case D460 in Appendix B for additionaldetails.)
CMS officials reported that MAOs may use internal clinical criteria that do not
contradict Medicare coverage rules; however, existing guidance is not
sufficiently detailed for OIG to determine whether CMS would consider each of
these denials in our sample to be inappropriate
In severalcases, we were unable to determine whether the prior authorization denials
that met Medicare coverage rules would be considered allowable by CMS because
CMSs guidance regarding MAO use ofinternal clinicalcriteria is not sufficiently
detailed. The following example helps to illustrate the problem: An MAO denied a
prior authorization request for a CT scan (case D479)that our physician reviewers
determined was medically necessary. The MAO stated that its clinicalcriteriarequired
the beneficiary to have an x-ray first to prove that amore advanced imaging
procedure (a CT scan) was needed. However, the Medicare NCD for CT scans states:
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Findings|10 [T]here is nogeneralrule that requires other diagnostic tests to be tried before CT
scanning is used." This suggests thatallother things being equalMedicare would
have paid for the CT scan for this beneficiary if the beneficiary were enrolled in
original Medicare, whereas the service was denied for the beneficiary in Medicare
Advantage.
The section ofthe Medicare Managed Care Manualgoverning this issue states that
MAO internalpolicies for medicalnecessity determinations must use coverage
criterianomore restrictive than originalMedicares national and local coverage
policies.23 In the example above, because the Medicare coverage rule does not
require a beneficiary to have an x-ray prior to a CT scan, and because theNCD states
specifically that there is nosuch requirement in original Medicare, one could conclude
that the MAO used criteriathat were more restrictive than original Medicare.
CMSofficials reported to OIG that MAOs may establish additionalclinicalcriteriafor
Medicare-covered services, as long as the criteriaare evidence-based and donot
contradict the applicable Medicare coverage rules. Therefore, in the example above,
the denialof prior authorization for the CT scan could be considered allowable if CMS
judged that the MAOs x-ray requirement was evidence-based and did not contradict
the Medicare NCD for CT scans.
Given the current language in the Medicare Managed Care Manual, and because CMS
has not issued guidance on what types ofclinical criteriawould be considered more
restrictive than or contradictory to Medicare coverage rules, OIG was unable to
determine whether certain denials of Medicare-covered services would be considered
allowable by CMS.
MAOs denied prior authorization requests for medically
necessary services when providers did not respond to requests
for unnecessary documentation
In some prior authorization cases in our sample that met Medicare coverage rules,
MAOs contacted providers to request unnecessary documentation (e.g., additional
test results)before making their decision, and then denied the request when
providers did not supply the additionaldocumentation. In some of these cases, the
MAO reviewer requestedadditionaldocuments to further supportthat the requested
service was medically necessary; however, our physicians determined that the clinical
information in the case file was already sufficient to demonstrate medical necessity.
In other cases, the MAO reviewer asked for copies ofdocumentation already
contained in the case file.
Case D199: MAO requested documentation that was already on file.
An MAO denied a request for Botox medication for a beneficiary with a diagnosis of
urge incontinence (estimated cost $3,674). The MAO incorrectly stated that there was
23CMS,MedicareManagedCareManual,ch.4,sec.10.16.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Findings|11 a lack ofclinicalinformation about the beneficiarys previoususe ofthe medication
and asked for additionalrecords. However, the MAO had already received records
documenting the beneficiarys previous use ofBotox as part ofthe prior authorization
request, making the request for the documentation unnecessary. (The MAO noted
that itreversed the denialafter receiving OIGs data request. See case D199 in
Appendix B for additionaldetails.)
Eighteen percent of payment denials were for claims that met
Medicare coverage rules and MAO billing rules, which delayed
or prevented payments for services that providers had already
delivered
Of the 160,378 paymentdenials issued by the 15 selected MAOs during the first week
ofJune 2019, an estimated 18 percent met Medicare coverage rules and MAO billing
rules and should have been approved by the MAOs.24 This projects to 28,949
paymentdenials that metMedicare coverage rules and MAO billing rules for the
selected MAOs during that week. For an annualcontext, if these MAOs denied the
same number ofpayment requests (28,949)in each ofthe other 51 weeks of2019,
they would have denied 1.5 million paymentrequests that met Medicare coverage
rules and MAO billing rules that year. Denying payment requests that meet these
rules delays or preventsproviders from receiving payment for services that they have
already delivered to beneficiaries, which can burden providers.
MAOs denied payments to providers because of human error
during manual reviews
MAOs rely on their staff to manually reviewsome requests for payments before
approving or denying them. However, these manualreviews are susceptible to
human error, such as a reviewers overlooking a document in the case file or
inaccurately interpreting CMS or MAO coverage rules. Theseerrors can resultin
denied payments to providers for services that meet Medicare coverage rules and
MAO billing rules.
24Asstatedonpage4ofthisreport,in2018,MAOsdenied9.5percentofallpaymentrequestsinthe
MedicareAdvantageprogram.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Findings|12 Case D187: MAO reviewer was unfamiliar with network facility coverage
rules.
An MAO reviewer denied a payment requestfor care at a skilled nursing facility
because itwas delivered by a provider whowas not contracted with the MAO
(estimated cost$50). In most cases, a beneficiary needs prior authorization to receive
care from a noncontracted provider. However, the skilled nursing facility was
an in-network facility. This qualified the claim as plan-directed care, and therefore
noprior authorization was required. The MAO attributed the denialto human error.
(The MAO noted that it reversed thedenialafter receiving OIGs data request. See
case D187 in AppendixB for additionaldetails.)
Case D442: MAO reviewer did not account for documentation already on
file.
An MAO denied payment for radiation treatment for an elderly cancer patientwith
a tumor on the pancreas($336). The MAO incorrectly claimed that no prior
authorization had been submitted for the service. However, the provider
subsequently submitted ascreenshotdemonstrating that the MAO had granted
a prior authorization for the billed claim. The MAO attributed this denial to human
error and reversed the denial, noting that the MAOs reviewer did not see the prior
authorization in the file. (See case D442 in AppendixB for additionaldetails.)
MAOs denied payment requests because of inaccurate
programming of claims processing systems
When MAO systems for claims processing are programmed incorrectly, or are not
updated timely, they canresultin denials for payments that should be approved.
Unlike errors generated on a case-by-case basis during a manualreview, system
errors can cause greaterharm because they automatically generate a potentially
larger volume of incorrectdenials untilthe MAO notices the error and fixes it.
Case D444: MAOs system failed to correctly route claims for manual review.
One MAOs established procedure was to manually review payment requests from
providers with multiple taxpayer identification numbers (TINs)so that the correct TIN
could be chosen. However, the system was programmed incorrectly and did not
automatically route these cases for manualreview. In this case, an in-network
provider submitted a claim for physicaltherapy services, butthe MAOs system chose
an incorrect TIN, making the provider appear to be out-of-network. The MAO
discovered the error after receiving OIGs data request and paid the claim ($108). The
MAO reported to OIG that the same error may have affected 163 additionalprovider
paymentrequests and that it was working to implement an automated process to
prevent areoccurrence. (See case D444 in AppendixB for additionaldetails.)
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Findings|13 Case D441: MAOs system did not recognize the authorized timeframe for a
service.
An MAO denied a request for radiation therapy ($668)for a 74-year-old beneficiary
with prostate cancer, incorrectly stating that noprior authorization was on file for the
date ofservice. The provider disputed the denialand submitted a screenshot
demonstrating that prior authorization had previously been obtained. The MAO
stated that its system had not correctly recognized the timeframe that had been
authorized under the approved prior authorization request. The MAO reversed the
denialand reported that itupdated its system to correctthe error. (See case D441 in
Appendix B for additionaldetails.)
Imaging services, stays in post-acute facilities, and injections
were three prominent service types among the denials that met
Medicare coverage rules
Among the denied requests for prior authorizations and payments that met Medicare
coverage rules and MAO billing rules that we identified in our sample, there was
a wide range ofservice types. Three ofthe most prominent service types were
advanced imaging services (including MRIs and CT scans); post-acute care in skilled
nursing facilities and inpatientrehabilitation facilities (i.e., care after hospitalstays);
and injections.25 To reduce their costs, MAOs may have an incentive to deny more
expensive services, such as inpatient rehabilitation facility stays, and/or require that
beneficiaries receive less expensive alternatives. We also observed denials that met
Medicare coverage rulesand MAO billing rules for items or procedures that may
receive extra scrutiny from MAOs because they can be vulnerable to fraud, such as
durable medicalequipment and injections for pain management.26
MAOs denied requests for advanced diagnostic imaging that met
Medicare coverage rules and MAO billing rules, often stating that
a more basic imaging service must be performed first
Imaging services were the most common health care service type among the denials
that met Medicare coverage rules and MAO billing rules in our sample, and consisted
mainly of advanced diagnostic imaging services,such as MRIs and CT scans.
Medicare coverage rulesstate that MRIs and CT scans are covered when medically
25Wealsoobserveddenialsforphysicianservices,durablemedicalequipment,surgery,inpatienthospital
stays,ambulancetransport,labtests,therapy,radiationtreatment,chiropracticservices,andothertests.
SeeAppendixBformoredetailonthedenialcasesinoursamplethatmetMedicarecoveragerules.
26Durablemedicalequipmentandinjectionsforpainmanagementhavebeenthesubjectofmany
prosecutionsforhealthcarefraud. See,forexample:DepartmentofJustice,CEOSentencedtoPrisonin
$150MillionHealthCareFraud,OpioidDistribution,andMoneyLaunderingScheme. Accessedon
March21,2022.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Findings|14 necessary and appropriate for the beneficiary.27 Medicare does not have a blanket
requirementthat beneficiaries receive specific tests or treatments prior to receiving an
MRI or CT scan.28 However, in severalcases MAOs denied requests for advanced
diagnostic imaging that our physician paneldetermined were medically necessary,
and that health care codingexperts determined met Medicare coverage rules,
because thebeneficiary had not first received a more basic imaging service or more
conservative treatment. As discussed earlier in this report, MAOs often cited MAO
clinicalcriterianot contained in Medicare coverage rules to justify these denials of
imaging services.
Case D221: MAO required an x-ray before it would approve an MRI.
An MAO denied a request for an MRI (estimated cost$365)ofthe hand for
a Medicare beneficiary whocontinued to have pain and weakness in the hand
5 months after a fall. The MAO cited its clinicalcriteriathat required, among other
things, that the beneficiary undergoan x-ray that then failed toprovide a diagnosis
before the MAO would authorize an MRI. However, our reviewers determined that
the MRI was medically necessary and reasonable for the beneficiary and the
applicable Medicare NCD does not have a requirement that a beneficiary receive an x-
ray prior to an MRI. Further, our physician panelexplained that an x-ray would not be
sufficient for this patient because some hand injuriessuchas those involving small
bones, muscles, and ligaments in the handmay not be visible with an x-ray. The
physician panelalso noted that delayed treatment could cause further harm for this
beneficiary because themuscles andligaments might retract. The MAO reversed the
prior authorization denialupon appeal. (See case D221 in AppendixB for additional
details.)
Case D406: MAO required provider-directed treatment before it would
approve an MRI.
An MAO denied a request for an MRI (estimated cost$297)for a 91-year-old
beneficiary with worsening chronic lowback pain with sciatica (pain that radiates from
the lower back through the hips and down the leg). The MAOs medical director
denied the request because the beneficiary had not completed 6 weeks of
provider-directed treatment within the preceding 3 months. However, our physician
paneldetermined that the beneficiary needed the MRI because ofthe beneficiarys
age, the diagnosis, and the results ofa previous back x-ray. Further, theNCD for MRIs
does not require that beneficiaries complete 6 weeks ofprovider-directed treatment
before receiving an MRI. (See case D406 in AppendixB for additionaldetails.)
27CMS,NationalCoverageDetermination(NCD)forComputedTomography(220.1),March12,2008.
CMS,NationalCoverageDetermination(NCD)forMagneticResonanceImaging(220.2),April10,2018.
28Inindividualcases,theuseofanMRIorCTscanastheinitialdiagnostictestmaynotbereasonable
andnecessarybecauseitisnotsupportedbythebeneficiaryssymptoms(anditwouldthenbe
appropriatetodenytherequestfortheadvancedimagingandsuggestmoreconservativetreatment
first).
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Findings|15 MAOs denied requests for transfers to post-acute care facilities
that met Medicare coverage rules, claiming that beneficiaries
needs could be met at a lower, less costly level of care
Among the denialcases that metMedicare coverage rules in our sample, severalwere
prior authorization requests to discharge patients from the hospitalto inpatient
rehabilitation facilities or to skilled nursing facilities. In their justifications for these
denials, MAOs often claimed that the patients did not need intensive therapy or
skilled care, and that their needs could be met at a lower levelof care, such as home
health services at the patients residence. However, our physician paneldetermined in
these casesthat the patients met the clinicalcriteriafor admission to the relevant
facilities, that they would have benefited from the higher levelofcare ordered by the
requesting physician, and that the alternatives offered by theMAOs were not clinically
sufficient to meetthe patients needs.
Post-acute services provided in facilities for rehabilitation and skilled nursing care are
significantly more expensive than home health services, which may lead to increased
scrutiny from MAOs for these typesofrequests. (See Exhibit 2.)
Exhibit 2: Costs for post-acute care can vary widely across different settings
Inpatient rehabilitation facilities provide intensive therapy and medical services in
a hospital environment to patients with complex nursing, medicalmanagement, and
rehabilitative needs.
Average payment per stay in 2018 under original Medicare: $20,124.
Skilled nursing facilities provide skilled nursing or therapy services to patients for
rehabilitation following inpatienthospitalstays.
Average payment per stay in 2018 under original Medicare: $11,592.
Home health services include intermittent skilled nursing care, physicaltherapy, or
speech-language pathology, and continuing occupational therapy services for
patients whoare unable to leave home or can leave home only with considerable
effort.
Average payment per stay in 2018 under original Medicare: $3,089.
Sources:CMS,InpatientRehabilitationTherapyServices:ComplyingwithDocumentationRequirements,Medicare
CoverageofSkilledNursingFacilitycare,andMedicareHomeHealthBenefitBooklet. Informationoncostsfrom:
MedicarePaymentAdvisoryCommission,ADataBook:HealthCareSpendingandtheMedicareProgram,July2020.
SkillednursingfacilitycostscalculatedusingthenumberofMedicareskillednursingfacilitystaysandtotal
Medicareskillednursingfacilitypayments.
Case D260: MAO offered an insufficient alternative level of care.
An MAO denied a request to transfer a beneficiary from the hospitalto a skilled
nursing facility, stating that alower levelofcare (home health services)could meet
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Findings|16 the beneficiarys medicalneeds. The beneficiary had pain and swelling from cellulitis
(a bacterial skin infection)and bedsores. The patient was unable to carry outactivities
ofdaily living, could stand for only a few minutes at a time, and was no longer able to
walk with the help ofa rolling walker. Our physician paneldetermined that,
considering the beneficiarys deteriorating functionalstatus, comorbidities, and need
for daily skilled care, the patient met Medicare coverage requirements for skilled
nursing facility care outlined in the Medicare BenefitPolicy Manual and would benefit
from occupational and physicaltherapy. The MAO reversed this denialupon appeal.
(See case D260 in Appendix B for additionaldetails.)
Case D278: MAO denied care that met patients needs.
An MAO denied a request for areferralto an inpatient rehabilitation facility for a
beneficiary with a fractured femur whowas recovering from screw placement surgery.
The MAO stated that the beneficiary did not meet allmedicalnecessity criteriafor
admission toan inpatient rehabilitation facility, and that the beneficiarys needs could
be met in other, lower-level-of-care settings, suchas a skilled nursing facility, home
with home health services, or home with outpatient therapy. However, our physician
paneldetermined that the beneficiary met the medicalnecessity criteriafor an
inpatient rehabilitation facility stay as outlined in the Medicare BenefitPolicy Manual,
including the need to be examined by a rehabilitation physician at least 3 days per
week. The physician reviewer added that a lower levelof care was not a clinically
sufficient alternative because the beneficiary would not have access to physician
supervision to facilitate recovery from pneumoniaand other post-operative risks.
(See case D278 in Appendix B for additionaldetails.)
MAOs denied requests for injections, in some cases by
misapplying Medicare coverage rules
A third prominent service type among the denials that met Medicare coverage rules
in our sample was injections. Some ofthese injections were for pain management,
which have been subjectto improper billing and fraud in Medicare, and somay
receive extra scrutiny from MAOs. However, in two ofthe pain-management injection
cases in our sample, case reviews determined that MAO reviewers misapplied
Medicare coverage rules(see examples below).
Case D401: MAO misapplied Medicare coverage rules.
An MAO denied a request for an injection to alleviate severe and worsening neck pain
for a 72-year-old beneficiary. The request was for an injection in the cervical1-2 joint
between the firstand second vertebrae at the top ofthe spine (estimated cost$238).
The MAO stated that the LCD allowed for that type ofinjection only for lower areas of
the spine. However, our physician paneldetermined that the injections were
medically necessary given the beneficiarys chronic, continuous pain, and our health
care codingexpert determined that the LCD referenced by the MAO did not preclude
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Findings|17 the use ofinjections in the cervical1-2 joint. (See case D401 in Appendix B for
additionaldetails.)
Case D475: MAO misstated Medicare coverage utilization limits.
An MAO denied a request for facet joint injections in three sections ofthe spine
(estimated cost$95), incorrectly stating that the number ofinjections requested
exceeded the Medicare coverage limitof: (1) one to two injections per section of the
spine per session, or (2) up to five injection sessions in a 12-month period. Our
physician paneldetermined that the injections were medically necessary and
reasonable because thebeneficiary, whohad degenerative osteoarthritis ofthe spine
and a history ofneck, low back, and hip pain, had reported significant relief from two
prior injection sessions. Further, our health care codingexpert determined that the
LCD that the MAO cited does not include a limit on the number ofinjections per
section ofthe spine per session, and that the requested session would not cause the
beneficiary to exceed five sessions in a 12-month period. (See case D475 in Appendix
B for additionaldetails.)
MAOs reversed some initial prior authorization denials and
payment denials for requests that met Medicare coverage rules
and MAO billing rules
For 3 percent ofprior authorization denialcases, and 6 percent ofpayment denial
cases, MAOs initially denied requeststhat met Medicare coverage rules, and then
reversed their decisions before our data request (within 3 months ofthe original
denial).29 Although reversed denials for prior authorization requests mean that
beneficiaries ultimately were offered coverage for needed care, the process alsocan
create a burden for beneficiaries who need to navigate the appeals process. Similarly,
reversed denials for paymentrequests mean that providers were ultimately paid for
the servicesthat they delivered. However, each denialfor a payment request that met
Medicare coverage rulesand MAO billing rules represents acase in which providers
were delayed payment and/or had to dispute a denialthat ideally would have been
approved upon the first request. These avoidable delays and extra steps create
friction in the program and may create an administrative burden for beneficiaries,
providers, and MAOs.
29WerequestedcasefiledocumentationinSeptember2019,3monthsafterMAOsissuedtheinitial
denials. Inasmallnumberofcases,MAOsdiscoverederrorswhilepreparingcasesfilesforourdata
requestandnotifiedOIGthattheyreversedthedenials. Becausewedonotknowifthesereversals
wouldhaveoccurredintheabsenceofourdatarequest,wedidnotincludetheminourestimates.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Findings|18 MAOs reversed some denials for prior authorization requests
following beneficiary appeals
For 3 percent ofprior authorization denials, MAOs initially denied requests that met
Medicare coverage rules,and later reversed thesedenials within 3 months and
approved the requests. Most ofthese reversals occurred because beneficiaries or
their providers filed appeals. Among the denials for prior authorization requests in
our sample that met Medicare coverage rules and that were appealed, MAOs reversed
all ofthe denials and authorized all ofthe requested services.
Case D421: MAO delayed a CT scan by 5 weeks for a beneficiary with cancer.
An MAO denied a request for a CT scan ofthe chest and pelvis for abeneficiary with
endometrial cancer. Theprovider was able to get the denialreversed 5 weeks after
the initialrequestby submitting additionalinformation and filing an appeal.
However, our physician paneldetermined that the originalrequest had sufficient
documentation to demonstrate that the CT was needed to assess the stage ofthe
cancer and to determine the appropriate course oftreatment. Delayed care can
negatively affect beneficiary health, particularly for urgent conditions. Our physician
reviewer noted the importance oftimely monitoring the growth and extent ofcancer
to assess severity ofthe disease and determine the course oftreatment. (See case
D421 in Appendix B for additionaldetails.)
MAOs reversed some payment denials following provider
disputes
For 6 percent ofpayment denials, MAOs initially denied payment requests that met
Medicare coverage rulesand MAO billing rules, and later reversed these denials
within 3 months and paid the claims. In some cases, providers presentedevidence in
their dispute that the MAO should have approved payment, such as screenshots that
the MAO had previously approved a prior authorization for the service that had been
provided. (See cases D073, D119, and D441 in AppendixB.) In other cases, the
providers dispute prompted the MAO to acknowledge system or manualerrors that
resulted in payment denials, such as incorrect configuration of provider coverage
details. (See case D116 in AppendixB.)
Case D489: MAO acknowledged that prior authorization was not required
after the provider disputed the denial.
An MAO denied payment for x-ray services for a patient with osteoarthritis, incorrectly
stating that prior authorization was required for the x-rays. The provider disputed the
denialand included screenshots ofan emailexchange with a plan representative who
confirmed that prior authorization was not needed. On reviewing the dispute, the
MAO acknowledged its error and reversed the denial, and then paid the claim ($102).
(See case D489 in Appendix B for additionaldetails.)
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 Findings|19 CONCLUSION AND RECOMMENDATIONS
As Medicare Advantage enrollmentcontinues to grow, MAOs play an increasingly
criticalrole in ensuring that Medicare beneficiaries have access to medically necessary
covered services and that providers are reimbursed appropriately. MAOs are
expected both to ensure access to high-quality care and to implement critical
program controls in order to avoid unnecessarycosts and ensure program integrity.
However, capitated payment models, such as Medicare Advantage, can create an
incentive for MAOs to deny the prior authorization ofservices for beneficiaries, and
payments to providers, including some servicesand payment that would not have
been deniedin original Medicare. Denied requests that meet Medicare coverage
rules may prevent or delay beneficiaries from receiving medically necessary care and
can burdenproviders. Even when denials are reversed, avoidable delays and extra
steps createfriction in the program and may create an administrative burden for
beneficiaries, providers,and MAOs. Further, beneficiaries enrolled in Medicare
Advantage may not be aware that there may begreater barriers to accessing certain
types ofhealth care services in Medicare Advantage than in original Medicare.
Our findings aboutthe circumstancesunder which MAOs denied requeststhat met
Medicare coverage rulesand MAO billing rules provide an opportunity for
improvementto ensure that beneficiaries enrolled in Medicare Advantage have timely
access to all necessary health care services, and that providers are paid appropriately.
In some cases, the MAOs identified their own errors and reversed the denials, in
others, MAOs reversed denials following appeals. This suggests that improvement
efforts by MAOs could reduce the number ofsimilar errors in the future. The causes
ofother cases ofdenied prior authorization and payments for services that met
Medicare coverage rulesand MAO billing rules warrant further action by CMS,
including guidance to MAOs and CMSs oversight audits.
Therefore, we recommend that CMS:
Issue new guidance on the appropriate use of MAO clinical
criteria in medical necessity reviews
To help ensure that Medicare Advantage enrollees receiveallmedically necessary and
covered services, to help promote MAO compliance with Medicare coverage rules,
and to help improve program transparency, CMS should issue new guidance on both
the appropriate use and the inappropriate use of MAO clinicalcriteriathat are not
contained in Medicare coverage rules. The guidance should clarify what the Medicare
Managed Care Manual means when itsays that MAO clinical criteriamustnot be
more restrictive than Medicare coverage rules,and itshould include specific
examples of criteriathat would be considered allowable and unallowable. CMS
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaise
ConcernsAboutBeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 ConclusionandRecommendations|20 should also instruct MAOs to examine and revise their procedures for making
coverage determinations, as needed,considering CMSs new guidance.
Update its audit protocols to address the issues identified in this
report,such as MAO use of clinical criteria, and/or examine
particular service types
CMSshould update its auditprotocols to look for issues identified in this report.
Although CMSs audit protocols already direct auditors to review asample of denial
cases to determine whether the denials were issued appropriately, CMS should add
additionalprompts for auditors. For example, following the publication of the new
guidance relating to the use ofclinicalcriteria in medicalnecessity reviews, CMS could
add questions for auditors in section 3.2 ofits auditprotocol(ClinicalAppropriateness
of Denials) to determine whether MAOs are following the newguidance. Similarly,
CMScould add a question for auditors examining whether MAOs requested
unnecessarydocumentation.
IfMAOs are found to be noncompliant because they are using more restrictive clinical
criteriaor requesting unnecessary documentation, CMS should follow its normal
enforcementaction process, including adding aggravating factors in civil money
penalty calculations if MAO denials resulted in beneficiaries not being able to access
needed services. Further, CMS should consider additionalenforcement actions for
MAOs that demonstrate a pattern ofinappropriate payment denials.
CMSalsoshould consider targeting in its audits specific service types that have a
history of inappropriate denials, which could include the service types identified in
this report. CMS could choose to focus on service types for which inappropriate
denials may have a significant impact on beneficiary health and well-being, such as
stays in post-acute facilities. Selecting a targeted sample may increase the likelihood
offinding inappropriate denials.
Direct MAOs to take additional steps to identify and address
vulnerabilities that can lead to manual review errors and system
errors
Although some ofthe denials discussed in this report were attributable toone-off
human errors, others seemed preventable through process orsystem changes by
MAOs. CMS should direct MAOs to examine their processesfor manualreview and
system programming and remediate vulnerabilities that may resultin inappropriate
denials. For example, CMS could point to this report, including the detailed
explanations ofthe errors in AppendixB, to help MAOs identify the types oferrors
that they should be looking for. To help avoid system errors,CMS could direct MAOs
to take additional steps to ensure that any changes affecting coverage or payment
(especially those on an established schedule, such as renewalofa providers contract
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaise
ConcernsAboutBeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 ConclusionandRecommendations|21 with the MAO), are properly coded in their systems. CMS could also direct MAOs to
consider additionalstaff training on documentation that should be verified before
issuing a denial, and the levelofdocumentation required.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaise
ConcernsAboutBeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 ConclusionandRecommendations|22 AGENCY COMMENTS AND OIG RESPONSE
In responseto the draft report, CMS stated that it is committed to oversight and
enforcementofthe requirements of the Medicare Advantage program and concurred
with allthree recommendations. CMSreiterated that MAOs mustfollow Medicare
coverage rules. CMS further stated that MAOs may implementadditionalcoverage
requirements to better define the need for a service as long as the additional
requirements do not violate the requirements in the relevantNCD or LCD. However,
as we note in our report,this statement is not clearly outlined in existing guidelines.
CMSconcurred with the first recommendation to issue new guidance on the
appropriate use ofMAO clinicalcriteriafor medical necessity reviews, stating that it
plans to issue such guidance.
CMSconcurred with the second recommendation to update its auditprotocols to
address the issues identified in this report, suchas MAO use ofclinicalcriteriaand/or
examining particular service types. CMSstated that it willupdate its auditprotocol
and auditor training materials, as needed, to align with the guidance that itplans to
issue underthe first recommendation. CMS did not indicate whether itwould
consider targeting in its audits specific service types that have ahistory of
inappropriate denials.
CMSconcurred with the third recommendation to direct MAOs to take additional
steps to identify and address vulnerabilities that can lead to manualreviewerrors and
system errors. CMS stated that it would direct MAOs to examine their manualreview
and system programming processesand to address vulnerabilities that may resultin
inappropriate denials. Although CMS stated that these efforts would be in keeping
with the guidance that it plans to issue in response to the first recommendation, OIG
notes that the manualreview errors and system processing errors identified in this
reportwere unrelated toreviews for medicalnecessity.
For the fulltext of CMSs comments, see Appendix D.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaise
ConcernsAboutBeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 AgencyCommentsandOIGResponse|23 DETAILED METHODOLOGY
Sample selection
MAO selection. To select the MAOs for this review, we used CMS PartC enrollment
data to identify the number ofbeneficiaries in health maintenance organization
(HMO)plans and preferred provider organization (PPO)plans administered by each
MAO in June 2019. We selected 15 ofthe largest MAOs by enrollment. The
15 selected MAOs accounted for nearly 80 percent ofbeneficiaries enrolled in
Medicare Advantage in June 2019, ranging in size from about 165,000 to nearly
6 million beneficiaries.
Case selection. We collected a list ofallprior authorization denials and payment
denials that each selected MAO issued during a 1-week period, June 17, 2019
(282,830 totaldenials). We created asampling frame from this list by grouping
denials into 7 strata based on denial type (prior authorization or payment)and the
number ofdenials issued by the MAO during that week. From this sampling frame,
we selected a stratified random sample of500 cases (250 prior authorization denials
and 250 payment denials).
We stratified by denialtype in order to make projections of the rates of prior
authorization denials and payment denials that were issued for requests that met
Medicare coverage rulesand MAO billing rules. We alsostratified by MAO size. We
under-sampled MAOs with larger numbers ofdenials to avoid over-burdening them
with a high number ofrequests for case file documentation. See Exhibit 3 on page 26
for a description ofeach stratum, sample size, and population ofdenial cases.
Excluding ineligible cases. We instructed MAOs to exclude certain denials, such as
those for supplemental services andclaims with third-party liability, from the lists of
prior authorization denials and payment denials that they submitted. During the
course ofour review, we identified and excluded additionaltypes ofineligible cases
from our analysis.
We identified 70 ineligible cases in our originalsample of500 cases, making our final
sample 430 cases (183 payment and 247 prior authorization cases). Typesofdenials
that were ineligible for this review included:
 Services already paid for under another paymentarrangement: In some cases,
MAOs pay providers under a capitated arrangement. Providers may bill the
MAO todocument a service/encounter with the beneficiary, and these bills
can create the appearance ofa denial, but providers donot expect
reimbursement for the specific services in addition to the capitated payment
that they are already receiving. These cases were ineligible for this study
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcerns
AboutBeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 DetailedMethodology|24 because theMAO did not make acoverage decision based on the merits of
the case, and there was noexpectation ofpayment to the provider.
 Cases denied because ofa GY modifier: In some cases, providers may billfor a
service that they know willnot be covered (for example, to get a record of a
Medicare denialbefore billing secondary insurance). They may attach aGY
modifier tothe HCPCS (Healthcare Common Procedure Coding System)code
on the claim, which signals that the claim should not be paid. These cases
were ineligible for this study because providers were not requesting payment.
 Exact duplicates: In some cases, system or human errors maycause the same
claim to be submitted from a provider to the MAO more than once. Cases
that were denied as exact duplicates were ineligible for this study because
they were not denials based on the merits ofthe case.
 Services paid by Medicaid for beneficiaries dually eligible for Medicare and
Medicaid: Some beneficiaries who are dually eligible for both Medicare and
Medicaid are enrolled in specialplans through which a single MAO
administers both their Medicare and Medicaid benefits. Some ofthese MAO
systems aresetup to process requests for certain services asMedicare
denials before they will approve and pay for them under the beneficiarys
Medicaid benefit. These cases were ineligible for this study because they
were not true denials based on the merits ofthe case, but rather a system
processing step.
 Supplemental services: MAOs are allowed to cover extrahealth and wellness
services thatare not normally covered under Medicare, suchas gym
memberships. These supplemental services arenot covered by all MAOs.
These caseswere ineligible for this study because the services would not be
covered byoriginal Medicare, and the cases would have had different
coverage rules depending on the MAO.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcerns
AboutBeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 DetailedMethodology|25 Exhibit 3: Total and Eligible Denial Sample Sizes and Populations, by Stratum
Estimateof
populationof
Totalsample Populationof Eligible eligible
Stratum Casetype MAOs size denials samplesize denials
Prior TwolargestMAOsby
1 authorization volumeofdenialsfor 50 5,177 50 5,177
priorauthorization
Fourmedium-sized
Prior MAOsbyvolumeof
2 80 4,761 77 4,582
authorization denialsforprior
authorization
NinesmallestMAOsby
Prior
3 volumeofdenialsfor 120 2,514 120 2,514
authorization
priorauthorization
Totalpriorauthorizationcases 250 12,452 247 12,273
LargestMAOby
4 Payment volumeforpayment 70 150,405 31 66,608
denials
Sixmedium-sized
5 Payment MAOsbyvolumefor 85 100,402 64 75,597
paymentdenials
ThreesmallMAOsby
6 Payment volumeforpayment 45 12,570 42 11,732
denials
RemainingfiveMAOs
withthesmallest
7 Payment 50 7,001 46 6,441
volumeforpayment
denials
Totalpaymentcases 250 270,378 183 160,378
Totalcases 500 282,830 430 172,651
Case File Collection and Preliminary Screening
For the original500 sampled cases, we collected case file documentation in
September 2019 (3 months after the denials were originally issued). We requested
complete administrative and medical records from the MAOs. Among other
information, we requested that the MAOs provide a summary ofthe basic facts ofthe
case, an explanation oftheir reason for denying the request,any coverage rules that
MAOs cited to deny the request, records ofthe MAO decision-making process, copies
ofnotices sentto the beneficiary and/or provider, any medicalrecords on file, and
whether the denialhad been appealed.
To conduct the case file reviews, we contracted with health care coding and billing
professionals with expertise in Medicare coverage rules (health care coding experts)
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcerns
AboutBeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 DetailedMethodology|26 and with physicians. Health care coding experts used an OIG-developed protocolto
complete a preliminary screening for all500 cases in our sample. The first step ofthe
preliminary screening process was to determine whether the denialcase was eligible
for our sample (as described above). The health care coding experts thenreviewed
the case files ofthe 430 eligible cases for completeness and made additionalrequests
to the MAOs for missing records or information needed for case file reviews.
Case File Reviews
To design the case file review methodology, we consulted with the following: CMS;
the Medicare Advantage IndependentReview Entity contractor (which reviews denial
appeals that are upheld by MAOs); physicians; and health care coding experts. We
alsoreviewed CMS policy documents such as the Medicare Managed Care Manual.
The objective ofthe case file reviews was to determine whether the denied prior
authorization and payment requestsmet relevant Medicare coverage rules and, if
applicable, MAO billing rules. For our sample of 430 eligible cases, we conducted
reviews for administrative coverage only for 268 cases, and for the remaining 162
cases we conducted reviews for both administrative coverage and medical necessity.
Reviewers followed a structured protocolthat OIG developed in consultation with
health care coding experts and physicians.
Administrative coverage reviews. For denialcases that did not need a clinical
review to determine medicalnecessity, a health care coding expert followed a
structured OIG protocoltodetermine whether the denialmet the Medicare coverage
rules and/or MAO billing rules that the MAO cited as support for its denial decision.
Examples of cases that did not need a medicalnecessity determination included
denials that were issued because thebeneficiary was no longer enrolled with the
MAO; claims that were filed past required deadlines; claims for services that require
prior authorization but for which the MAO did not have an authorization on file; and
other administrative or billing inaccuracies. Health care coding experts reviewed the
MAOs justification for issuing the denialand determined whether the request met
applicable Medicare coverage rulesand MAO billing rules, such as NCDs and LCDs;
the Medicare Managed Care Manual; and the providers contract. They also examined
MAO coverage documents (i.e., the Evidence ofCoverage document for the
beneficiarys plan), and any other documentation in the case file that supported or
disputed whether the request metMedicare coverage rulesand MAO billing rules.
Medical necessity reviews. Ifthe health care coding experts assessedthat denial
cases needed a medical necessity review to determine whether the request met
Medicare coverage rules,then the cases receivedan additionalclinicalreview by a
physician. We assigned a physician reviewer to each of these cases on the basis of
the service type and the physicians specialty. Following a structured OIGprotocol,
physicians used their clinicaljudgment to determine whether the denied service was
medically necessary for the beneficiary using themedicalrecords and other clinical
information available in the case file. Physicians considered factors such as a
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcerns
AboutBeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 DetailedMethodology|27 beneficiarys symptoms, diagnosis, and medical history to determine medical
necessity and explain how they arrived at their decision. Physicians also determined
whether the MAO offered an alternate service to the beneficiary and ifso, whether the
alternate service was clinically sufficient to meet the beneficiarys needs.
For cases in which the physician reviewer indicated that the service was not medically
necessary for the beneficiary, OIG determined thedenialto be appropriate because
Medicare does not pay for services that are not medically necessary. For any case for
which the physician reviewer determined the service was medically necessary, or for
which the physician reviewer wanted to consult with other physicians, we conveneda
panelofthree physicians to discuss the case (see more on physician conference calls,
below). Services were determined to be medically necessaryifthe three-physician
panelreached consensus that the requested service was medically necessary for the
beneficiary.
For denied requests that the physician paneldetermined were medically necessary, a
health care coding expert reviewed the case to determine whether the request met
Medicare coverage rules. To do this, the health care coding expert reviewed the
circumstances ofthe case, including the specific justification(s)that the MAO cited to
deny the service and the panels explanation for why the service was medically
necessary. The health care coding expert then assessedconferring with the
physician reviewer as neededwhether the request met applicable Medicare
coverage rules and/or criteriafrom the MAO Evidence ofCoverage document.
Quality Assurance
To promote consistencyand accuracy across reviews, we issued a study-specific
guidance document for improved decision-making, provided training to all physicians
and health care coding experts, facilitated conference calls with the panelofphysician
reviewers, and conducted quality assurance reviews.
Guidance Document. We worked with the health care coding experts and physician
reviewers to develop a structured protocol to ensure thorough and consistentcase
reviews. We provided reviewers with a guidance document that included detailed
instructions for each question in the health care coding and physician protocols,
definitions for key terms, and a list offrequently asked questions. The guidance
included detailed instructions for determining whether a case was eligible for the
study, which types ofcases should be referred for physician review, and how to
determine whether adenialmet Medicare coverage and/or MAO billing rules.
Training. We provided two trainings for each reviewer type (i.e., health care coding
experts and physicians)regarding the OIG protocol for reviewing the denialcases.
The trainings included a review of the guidance document and an explanation ofthe
protocolquestions. We also conducted pre-test reviews with some reviewers to pilot
the protocols and give feedback to reviewers.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcerns
AboutBeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 DetailedMethodology|28 Physician Consensus Calls. We facilitated regular conference calls for physician
reviewers to examine the medicalnecessity ofindividualcases and to promote
consistencyacross reviews. During these calls, physician reviewers discussed cases
that a physician reviewer assessed to be medically necessary or wanted to discuss
with the rest ofthe physician panel. Denialcases were determined to be medically
necessary if the physician reviewer and the physician panelreached consensus that
the case was medically necessary.
Quality Assurance Reviews. We reviewed health care coding expert and physician
protocolresponses to ensure that they were following the standardized review
protocols when assessing cases. We worked with the medicalreview contractor to
identify and address any inconsistencies across health care coding and physician
clinicalreviews. Separately, we worked with health care coding experts and physicians
to clarify or discuss anyquestions we had about their protocolresponses. We also
had a health care coding expert conduct independent secondreviews for a portion of
denialcases. Finally, we reviewed each case using the originalcase file and additional
information we collected from MAOs to ensure: (1)that it was eligible to be included
in our sample and (2)that protocol responses accurately reflected the circumstances
ofthe case.
Analysis
We analyzed the results ofthe reviews by health care coding experts and the clinical
reviews by physicians, and we generated population estimates ofthe prior
authorization denials and payment denials that met Medicare coverage rules and
MAO billing rules. We alsogenerated population estimates for the rates at which
MAOs initially denied prior authorization denials and paymentdenials in our sample
that met Medicare coverage rules and MAO billing rules, but then reversed their
decision before our data request (within 3 months). See AppendixA on page 31 for
point estimates, 95-percent confidence intervals, and key statistics.
To examine the reasons that denials occurred for requests that met Medicare
coverage rules and MAO billing rules, and the service types associated with those
cases in our sample, we conducted qualitative analysis of the case files and case
review results. We coded each denialthat met Medicare coverage rulesas resulting
from one or more ofsix causes that surfaced from the reviewed cases. Todetermine
the cause ofdenials for requests that met Medicare coverage rules, we examined the
MAOs justification for the denial, the results ofthe health care coding expert reviews
and/or physician clinical reviews, and relevantdocumentation in the case files. In
some cases, we determined that the denials resulted from more than one cause, for
example, when an MAO applied MAO clinical criterianot in Medicare coverage rules
and required unnecessary documentation. To describe service types, wecategorized
items or services using information from the case files. Because ofthe smallnumber
ofdenials within each stratum that metMedicare coverage rules, itwas not possible
to projectthe results ofthe denialcauses and service type categories.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcerns
AboutBeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 DetailedMethodology|29 To provide cost information for the denials in our sample that met Medicare coverage
rules, we reviewed case files to determine ifcost information was available. If
available, we included this information in AppendixB and in some of the case
examples presented in the report. For cases where the MAO reversed the denialand
documented paying for the service,we used the actualamount paid to the provider.
For all other cases, we used the actualor estimated cost ofthe denied service as
reported bythe MAO. Because a significant number ofcases in the sample did not
have cost data in their records, we were not able to estimate the overallcosts
associated with denials that met Medicare coverage rules.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcerns
AboutBeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 DetailedMethodology|30 APPENDIX A
Point Estimates and Confidence Intervals for Denials of Prior
Authorization and Payment Requests That Met Medicare
Coverage Rules, Issued by 15 Selected MAOs During June 17,
2019
95-Percent Confidence
Interval
Weighted
Description Frequency Percentage Lower Bound Upper Bound
Denialsofpriorauthorization 1,631 13.3% 8.9% 19.3%
requeststhatmetMedicare
coveragerules
Denialsofpriorauthorization 343 2.8% 1.4% 5.7%
requeststhatmetMedicare
coveragerulesandwerereversed
within3months
Denialsofpaymentrequeststhat 28,949 18.1% 11.7% 26.8%
metMedicarecoveragerules
Denialsofpaymentrequeststhat 10,140 6.3% 3.0% 12.9%
metMedicarecoveragerulesand
werereversedwithin3months
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 AppendixA|31 ual d) 365 32
act ate $ B|
( m x
Costor esti endi
p
p
A
t n
onaOIG uest upo
Rules Resolutitimeof qdatare Denial reversed appeal
e nt d
equestsThatMetMedicareCoverag tMetMedicareCoverageRules Denialsummary TheMAOdeniedtherequestandcitedinternalclinicalcriteria requiringaninconclusivex-rayanddocumentationthatthepatiehadnotimprovedwithmoreconservativetreatment.However, ourreviewersdeterminedthatanMRIwasnecessaryforthispatientandtheNCDforMRIsdoesnotrequirethatabeneficiary receiveanx-raypriortoreceivinganMRI.Ourphysicianpanel explainedthatanx-raywouldnotbesufficientforthispatientbecausesomehandinjuries,suchasthoseinvolvingsmallbones, muscles,andligamentsinthehand,maynotbeimmediatelyvisiblewithanx-ray.Thepanelnotedthatdelayedtreatment couldcausefurtherharmforthispatientbecausethemusclesan ligamentsmightretract. nRequestsRaiseConcernsAboutBeneficiaryAccessto
a o
nialsforR equestsTh Denialcause AppliedMAO clinicalcriterianotin Medicarecoveragerules Requiredunnecessary documentation PriorAuthorizati
e R of
ENDIXB ledDescriptionsofD AuthorizationDenialsof ServiceBeneficiaryrequestedprofile Imaging:MRIofA69-year-old righthandcontinuedtohavepainandwithoutcontrastweaknessinahand5months afterafall. dicareAdvantageOrganizationDenials NecessaryCare,OEI-09-18-00260
P i e y
AP Deta Prior CaseID D221 omeM Medicall
S ual d) 154 297 400 33
act ate $ $ $1, B|
( m x
Costor esti endi
p
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A
t
aG st d d d
olutioneofOI areque reverse reverse reverse
esm at ot ot ot
Rti d N N N
Denialsummary TheMAOrequestedunnecessaryadditionalmedicalrecordstosupportthescan,askingfortheresultsofthepreviouschestx-ray andCTscan.Whentheproviderdidnotsubmitthoseresultswithin1week,theMAOdeniedtherequest.TheMAOalsocited internalclinicalcriteriathatlimitedCTscansbasedonthesizeofnodulesandthereceiptofchestx-rays.However,ourphysician paneldeterminedthatgiventhepatientshistoryasasmoker,andthepresenceofalungnodule,thecasefilecontainedsufficient clinicalevidencetodeterminethattherequestedscanwasmedicallynecessary.Ahealthcarecodingexpertthendetermined thattherequestmetallotherapplicableMedicarerequirements,includingthattheNCDforCTscansdoesnotrequirepriorx-rays orthatthenodulesbeaspecificsize. TheMAOdeniedtheserviceandcitedinternalclinicalcriteria statingthatthepatienthadnotcompleted6weeksofprovider-directedtreatmentinthelast3months.However,ourphysician paneldeterminedtheMRIwasmedicallynecessarytoplantreatmentoptionsduetothepatientsage,symptoms,andresults ofapreviousbackx-ray.Further,theNCDforMRIsdoesnotstatethatcompletionofpriorconservativetherapyisneededbefore receivinganMRI. TheMAOdeniedtherequest,statingthatconductingaCTinthis contextwasinvestigationaland,therefore,notcoveredbyMedicare.However,ourphysicianpaneldeterminedthataCT scanwaswarrantedandwithinexpectedstandardsofcarebecauseitcouldmoreaccuratelyassesstheconditionoftheshoulderand determinetypeofsurgeryneeded.Further,theapplicableNCDdidnotindicatethattheuseofaCTscaninthiscontextwas consideredinvestigational. nRequestsRaiseConcernsAboutBeneficiaryAccessto
o
Denialcause Requiredunnecessary documentation AppliedMAOclinicalcriteria notinMedicare coveragerules AppliedMAO clinicalcriterianotin Medicarecoveragerules Determined thattherequestdid notmeetMedicare coveragecriteria PriorAuthorizati
of
Beneficiaryprofile A68-year-oldwhowasasmoker hadahistoryof lungnodules. A91-year-oldhad lowerextremitypainthatradiated intotheupperleg,hip,andlower back(sciatica).Backx-rays showedscoliosis andjointdisease. A77-year-oldhad ahistoryofleftshoulderpainthat hadprogressedforthelast3 years.Thepatienthadreceived therapyandinjections,butthe patientsconditionhadnot improved. OrganizationDenials EI-09-18-00260
Servicerequested Imaging:Chest CT Imaging:MRIof thelumbarspine withoutcontrast Imaging: ShoulderCTscanforpreoperative evaluation dicareAdvantage NecessaryCare,O
e y
CaseID D249 D406 D397 omeM Medicall
S (actual mated) Nocost available $150 $275 xB|34
Costor esti endi
p
p
A
t n
ResolutionatimeofOIG datarequest Denialreversedupo appeal Notreversed Notreversed
Denialsummary TheMAOdeniedtherequestandcitedinternalclinicalcriteriawhichrequiredinformationtosupportthatthediseasehadspread tothecervixorthatthetumorwasadvanced.However,ourphysicianpaneldeterminedthattherequestwasconsistentwith theapplicableNCDandhadsufficientdocumentationtoshowthattheCTscanwasneededtodeterminethestageofthecancer, whetherithadspread,andtodeterminetheappropriatecourseof treatmentforthebeneficiary. TheMAOdeniedtheCTscanandcitedinternalclinicalcriteriathatrequirepriorx-rayimagingresultstoprovemedicalnecessity.Our physicianpaneldeterminedtheCTscanwasneededtoexcludealife-threateningdiagnosis(aneurysm)consideringthebeneficiarys symptomsandcomorbidities.Further,theapplicableNCDdoesnotrequirethatapatientreceiveanx-raypriortoreceivingaCT scan. TheMAOdeniedtheMRIrequestandcitedinternalclinicalcriteriarequiringthatthebeneficiaryreceiveconservativetreatmentsfor6 weeks.However,ourphysicianpaneldeterminedanMRIwasmedicallynecessaryduetothebeneficiaryssignsandsymptoms ofhipchangesandalteredgait.Further,NCDguidelinesdonot requireconservativetreatmentpriortoanMRI. nRequestsRaiseConcernsAboutBeneficiaryAccessto
o
Denialcause AppliedMAOclinicalcriteria notinMedicare coveragerules Required unnecessarydocumentation AppliedMAOclinicalcriteria notinMedicare coveragerules AppliedMAOclinicalcriteria notinMedicare coveragerules PriorAuthorizati
of
Beneficiaryprofile An81-year-oldhad adenocarcinomaofthe endometrium,acancerofthe liningofthe uterus. A64-year-oldwithapacemaker, diabetes,hypertension,and heartvalvediseasewasseen forchestpainandshortnessof breath. A75-year-oldhadlefthippainand anx-rayshowingmilddegenerative changes.Anexamrevealeda limpcausedbythepain.The beneficiaryhadtriednonsteroidal anti-inflammatorydrugs,oral steroids,andimmobilization withabrace. OrganizationDenials EI-09-18-00260
O
Servicerequested Imaging:CTofchest,abdomen, andpelvis Imaging:Chest CT Imaging:MRIoflowerextremity jointwithout contrast dicareAdvantage NecessaryCare,
e y
CaseID D421 D479 D427 omeM Medicall
S ual d) 300 day 35
act ate $ per B|
( m x
Costor esti $425 endi
p
p
A
t n n
onaOIG uest upo upo
Resolutitimeof datareq Denialreversed appeal Denialreversed appeal
Denialsummary TheMAOdeniedtherequest(afterrequestingandnotreceivingadditionalrecords)statingthatthebeneficiarywouldneedtowait atleast1yearforanotherMRIgiventhesizeofthelargestlesion.TheMAOcitedinternalclinicalcriteriathatallowedfollow-upMRIs onlyat12monthsforalesionof1-2cminsizeorat6-12monthsforlesionsgreaterthan2-4cminsize.Ahealthcarecodingexpert determinedthattheapplicableNCDdoesnotrestrictthetimingofMRIsbasedonthesizeofthelesion.Furthermore,usingclinical informationalreadyinthecasefile,thephysicianpanelstatedtheMRIwasmedicallynecessarytodeterminewhetherthelesions seenontheCTscanweremalignant. TheMAOdeniedtherequeststatingthatthebeneficiarydidnothaveaneedforskilledcareinaccordancewithinternalclinical criteria.However,ourphysicianpaneldeterminedthattheadmissiontoaSNFwasmedicallynecessaryandconsistentwith theMedicareBenefitPolicyManualbecausethebeneficiaryrequiredphysiciansupervisionandshouldhaveaccesstophysical andoccupationaltherapy. nRequestsRaiseConcernsAboutBeneficiaryAccessto
o
Denialcause AppliedMAOclinicalcriteria notinMedicare coveragerules Requiredunnecessary documentation AppliedMAOclinicalcriteria notinMedicare coveragerules PriorAuthorizati
of
Beneficiaryprofile A65-year-oldhadahistoryofchest painthatradiatedtotheshoulder andleftjaw.Thebeneficiaryhada previousMRIshowingtwo adrenallesionsofindeterminate origin,thelargestofwhichwas1.5 cm. An81-year-oldhadahistoryof dementia,hypertensionand waslegallyblindduetoglaucoma. Thepatientwasadmittedtothe hospitalforworsening dementiaand acuteagitation. OrganizationDenials EI-09-18-00260
Servicerequested Imaging:MRIof abdomen Post-acutecare:Dischargetoa skillednursing facility(SNF) dicareAdvantage NecessaryCare,O
e y
CaseID D472 D236 omeM Medicall
S (actual mated) Nocost available Nocost available Nocost available xB|36
Costor esti endi
p
p
A
t n
ResolutionatimeofOIG datarequest Denialreversedupo appeal Notreversed Notreversed
Denialsummary TheMAOdeniedtherequeststatingthatitneededtoreviewthebeneficiarysmostrecenttherapyrecordsandsuggestedthatthe beneficiarysneedscouldbemeteitherinthecurrenthospitalsettingoratalowerlevelofcare(homehealthservices).Our physicianpaneldeterminedthatthemedicalrecordsavailabletotheMAOweresufficienttodemonstratethatgiventhe beneficiarysdeterioratingfunctionalstatusandmorbidities,thebeneficiaryshouldhavebeendischargedtoaSNFwithaccessto physicalandoccupationaltherapy.Further,ahealthcarecodingexpertdeterminedthattherequestforaSNFadmissionwas consistentwiththeMedicareBenefitPolicyManual. TheMAOdeniedtherequest,statingthatthebeneficiarydidnotmeetcoveragecriteriaforadmissiontoaSNFbecausethe beneficiarymaynotbeabletodo1to2hoursoftherapyperday.OurreviewersdeterminedthatSNFwasmedicallynecessaryfor thisbeneficiaryandinlinewiththeMedicareBenefitPolicyManual.Thebeneficiaryhadmultipleongoingmedicalconditions whichneeddailyskillednursingcare.Further,thebeneficiarycouldhavebenefitedfromandtoleratedoccupationalorphysical therapy. TheMAOdeniedtherequeststatingthatthebeneficiarys conditiondidnotmeetMedicarecoveragerulesforadmissiontoanIRF.However,ourphysicianpaneldeterminedthatadmission toanIRFwasmedicallynecessaryandinlinewiththeMedicareBenefitPolicyManual.Thebeneficiaryhaddifficultyswallowing, wasatsignificantriskofaspirationandfluidpenetration,athighriskforpneumonia,and,therefore,shouldhavebeenunderthe frequentsupervisionofarehabilitationphysician. nRequestsRaiseConcernsAboutBeneficiaryAccessto
o
Denialcause Requiredunnecessary documentation Determinedthatthe requestdidnotmeet Medicarecoverage criteria Determined thattherequestdid notmeetMedicare coveragecriteria PriorAuthorizati
of
Beneficiaryprofile A64-year-oldhadadiagnosisof cellulitis(abacterialskin infection)onlegandbedsoreswith complaintsofworsening swelling,redness,andpaininlower rightleg. A63-year-oldhadacomplex medicalhistoryincludingmultiple chemotherapyregimens, cognitiveimpairment,and priorstrokewastreatedinthe hospitalforcough,fatigue, andshortnessof breath. A67-year-oldwas diagnosedwithacuteright-sided ischemicstrokeandseenatthe emergencydepartmentwith newonsetslurred speech. OrganizationDenials EI-09-18-00260
e: e: e: e O
Servicerequested Post-acutecarDischargetoa SNF Post-acutecarDischargetoa SNF Post-acutecar Dischargetoaninpatient rehabilitation facility(IRF) dicareAdvantag NecessaryCare,
e y
CaseID D260 D426 D270 omeM Medicall
S (actual mated) Nocost available $3,039 xB|37
Costor esti endi
p
p
A
t n
ResolutionatimeofOIG datarequest Notreversed Denial reversedupo appeal
e r
Denialsummary TheMAOdeniedtherequeststatingthatthebeneficiarysconditiondidnotmeetallmedicalnecessitycriteriaforadmission toanIRFunderMedicareguidelines.TheMAOrecommendedinsteadthatthebeneficiarycouldbedischargedtoaSNF,home health,orhomewithoutpatienttherapy.Ourphysicianpaneldeterminedthattherecommendationsforoutpatienttherapywer notsufficientandthatadmissiontoanIRFwasnecessaryandconsistentwiththeMedicareBenefitPolicyManual.The beneficiaryhadongoingmedicalconditionsthatcouldgeneratemoremedicalcomplicationsifnotcloselyassessedbyaphysician daily.Thebeneficiaryalsohadtheabilityandneedtoparticipateinphysicaltherapyandoccupationaltherapyfor3hoursatleast 5daysperweek,neededhelpwithwalking,andatleasttwopeopletohelpwithbalanceandrecoveryfromthescrew placementinthebeneficiaryship. TheMAOdeniedtherequeststatingthatthebeneficiarydidnot haveamedicalproblemthatrequiredcareinanIRF.However,oureviewersdeterminedthattherequestedinpatientrehabilitation staymetrequirementsintheMedicareBenefitPolicyManualandwasmedicallynecessarybecauseitwouldallowthebeneficiaryto regaintheabilitytoperformtheactivitiesofdailylivingthatthe beneficiarywasabletodopriortothehospitaladmission. nRequestsRaiseConcernsAboutBeneficiaryAccessto
o
ti
a
e z
Denialcaus Determinedthatthe requestdidnotmeet Medicarecoverage criteria Determined thattherequestdid notmeetMedicare coveragecriteria PriorAuthori
of
Beneficiaryprofile A68-year-oldhadchronic obstructivepulmonary disease,congestiveheart failure,andperipheral vasculardisease.Thebeneficiary wasadmittedtothehospitalwitha femurfractureandunderwenta screwplacementsurgery.Afterthe surgery,thebeneficiary developedanemia andpneumonia. An89-year-old hadahistoryofParkinsons disease,dementia,andprostate cancerwhohadbeentreatedin theemergency department. OrganizationDenials EI-09-18-00260
e: e: e O
Servicerequested Post-acutecarDischargetoan IRF Post-acutecar Dischargetoan IRF dicareAdvantag NecessaryCare,
e y
CaseID D278 D343 omeM Medicall
S ual d) day 261 38
act ate per $ B|
( m x
Costor esti $750 endi
p
p
A
t n
ResolutionatimeofOIG datarequest Notreversed Denialreversedupo appeal
y s oe
Denialsummary TheMAOdeniedtherequeststatingthatthebeneficiarydidnotneeddailycarefromaphysician,asrequiredbytheMedicare BenefitPolicyManual.However,ourphysicianpaneldeterminedthatthebeneficiarydidrequirethislevelofcarefromaphysician duetothebeneficiaryscomplexhealthneedsandmedicalhistorandfeltthatthebeneficiarycouldtoleratetheleveloftherapyin theinpatientrehabilitationfacility.TheMAOsmedicaldirectoroffered5daysofskillednursingcare,butourphysicianreviewer judgedthatthisalternativecarewouldbeinsufficientforthis patient. TheMAOdeniedtherequeststatingthatthebeneficiarywasnotcurrentlyenrolledinorplanningtocompleteformaltherapyora homeexerciseprogram,arequirementfrominternalclinicalcriteria.However,ourreviewersdeterminedthattheinjectionwa medicallynecessarygiventhebeneficiarysdiagnostictestresultsandhistoryofcompletingconservativetherapywithoutrelief. Further,ahealthcarecodingexpertdeterminedthattherewasnNCDorLCDrelevanttothisservice,andthusthereisnoMedicar requirementthatbeneficiariesenrollinatherapyorexercise programbeforereceivingtreatment. nRequestsRaiseConcernsAboutBeneficiaryAccessto
o
ti
Denialcause Determinedthatthe requestdidnotmeet Medicarecoverage criteria AppliedMAOclinicalcriteria notinMedicare coveragerules PriorAuthoriza
of
Beneficiaryprofile A75-year-oldwashospitalizedafter amotorcycleaccidentwithrib fractures,acollapsedlung, andanacutekidneyinjury.The beneficiaryhadahistoryofheart attacks,irregularheartrate, diabetes,andchronic obstructivepulmonary disease. A66-year-oldsufferedneckpain fromdegenerativediscdiseasethat hadnotimprovedfromconservative therapy. OrganizationDenials EI-09-18-00260
Servicerequested Post-acutecare:Dischargetoan IRF Injection:Steroidinjectioninthe cervicalspine dicareAdvantage NecessaryCare,O
e y
CaseID D393 D224 omeM Medicall
S (actual mated) $3,674 Nocost available xB|39
Costor esti endi
p
p
A
ResolutionattimeofOIG datarequest Notreversed (MAOnoted thatitreversedthedenialafter receivingOIGs datarequest) Notreversed
Denialsummary TheMAOdeniedtherequestandcitedalackofclinicalinformationaboutthebeneficiaryspreviousmedicationuseand askedforadditionalrecords.However,theMAOhadalreadyreceivedrecordsdocumentingthisinformationaspartoftheprior authorizationrequest,makingtherequestforadditional documentationunnecessary. TheMAOdeniedtheinjectionrequestafteraskingformoredocumentation.TheMAOstatedthattheavailabledoctorsnotes didnotsupportmedicalnecessity.Ourphysicianpaneldeterminedthat,basedontheinformationavailableinthecase file,theinjectionwasmedicallynecessaryasopioidsandanti-inflammatorymedicationswerenotreasonablealternativesto managethepatientspain.Further,ourhealthcarecodingexpertdeterminedthattherequestmetrequirementsintheapplicable LCD. nRequestsRaiseConcernsAboutBeneficiaryAccessto
o
Denialcause Requiredunnecessary documentation Requiredunnecessary documentation PriorAuthorizati
of
Beneficiaryprofile An82-year-oldwasdiagnosed withurgeincontinence. Beneficiaryhadbeenreceiving Botoxinjections,butthe effectivenesswasperceivedtobe wearingoff,sorequesteda strongerdose. A66-year-oldhadlowerbackpain thatradiatedintothelegs.Patient hadbothkneesreplacedandused ashoelifttotreataleglength discrepancy.Patient experiencedsignificantpain whenstandingorwalkingwithno improvementfromprevious conservative treatments. OrganizationDenials EI-09-18-00260
Servicerequested Injection:Botoxinjectionforurge incontinence Injection:Sacroiliacjoint injectionforpain management dicareAdvantage NecessaryCare,O
e y
CaseID D199 D416 omeM Medicall
S ual d) 754 238 $95 40
act ate $ $ B|
( m x
Costor esti endi
p
p
A
t
aG st d d d
olutioneofOI areque reverse reverse reverse
esm at ot ot ot
Rti d N N N
Denialsummary TheMAOdeniedtherequeststatingthatthebeneficiarysbloodcountswerenotlowenoughtomeetrequirementsestablishedin internalclinicalcriteria.Ourreviewersdeterminedthattherequesteditemwasnecessaryandreasonablegiventhedownward trendinthebeneficiaryshemoglobincount,andthatthe beneficiarymettherequirementsintheapplicableNCD. TheMAOdeniedtheservicestatingthatperMedicarecoverage rules,therequestedinjectionswerecoveredonlyforthelowerareasofthespine,andnotattheC1-2joint.However,ourhealth carecodingexpertdeterminedthattheLCDreferencedbytheMAOdoesnotprecludetheuseofinjectionsintheC1-2joint. Further,ourphysicianpaneldeterminedthataninjectionatthislevelisareasonablediagnosticandtherapeuticoptionandthat theservicewasmedicallynecessarygiventhebeneficiaryschronic, continuouspain. TheMAOdeniedtherequeststatingthatthenumberofinjectionsrequestedexceededtheMedicarecoveragelimitof(1)onetotwo injectionspersectionofthespinepersession,or(2)uptofiveinjectionsessionsina12-monthperiod.However,ourhealthcare codingexpertdeterminedthattheLCDtheMAOciteddoesnotincludealimitonthenumberofinjectionspersectionofthespine persession,andthattherequestedsessionwouldnotcausethebeneficiarytoexceedfivesessionsina12-monthperiod.Further, ourphysicianpaneldeterminedthattheinjectionwasmedicallynecessaryandnotedthatthebeneficiaryexperiencedsignificant relieffromtwopreviousinjectionsessions. nRequestsRaiseConcernsAboutBeneficiaryAccessto
o
ti
Denialcause AppliedMAOclinicalcriteria notinMedicare coveragerules Determined thattherequestdid notmeetMedicare coveragecriteria Determinedthatthe requestdidnotmeet Medicarecoverage criteria PriorAuthoriza
of
Beneficiaryprofile A75-year-oldhadlowbloodiron levelcausedbyabnormalkidney function. A72-year-oldhad severe,worseningneckpain,and scansshoweddeteriorationand changesinspine.Beneficiaryhad triedotherconservative treatmentswithlimited improvement. A59-year-oldhadadiagnosisof spondylosis(degenerative osteoarthritisofthespine)anda historyofneckpain,lowback pain,andpainin bothhips. OrganizationDenials EI-09-18-00260
Servicerequested Injection:Injectiontotreat anemia Injection:Upper cervicalspine(C1-2)joint injection Injection:Cervical/thoracic facetinjection dicareAdvantage NecessaryCare,O
e y
CaseID D339 D401 D475 omeM Medicall
S (actual mated) 0/month $1,476 Nocost available xB|41
Costor esti $15 endi
p
p
A
t
aG st d d d
olutioneofOI areque reverse reverse reverse
esm at ot ot ot
Rti d N N N
Denialsummary TheMAOdeniedtherequest,incorrectlystatingthattheonlydiagnosislistedinthebeneficiarysmedicalrecordswas hypertension.Thisfindingledittodeterminethatthebeneficiarydidnotmeetinternalclinicalcriteriaforahospitalbedbecause therewasnoindicationofaconditionrequiringpositioningthatcouldnotbeaccommodatedbyastandardbed.However,our reviewersdeterminedtherequestwasmedicallynecessaryandinaccordancewiththeNCDforhospitalbedsduetothebeneficiarys chronicconditionsandmovementlimitations. TheMAOdeniedtherequestbasedoninternalguidelinesstating thattheliftwouldnotimprovethebeneficiarysbalanceorambulationandthatitisonlyforbeneficiarieswhorequire completeassistancewithsit-to-standtransfers.However,ourphysicianpaneldeterminedthatthisitemwasmedicallynecessary giventhepatientsmobilityneedsandprogressiveweaknessandtodecreasetheriskoffallsduringtransferstoandfrombed. Further,ourreviewersdeterminedthattheproposedusewas consistentwiththeapplicableLCD. MAOdeniedtherequestafterrequestingmoredocumentationfromthebeneficiarysdoctor.TheMAOstatedthatthepatientdid notmeetwheelchaircriteriafromMedicarecoveragerules,suchasdocumentationofwhetherthebeneficiarycouldpropelthe wheelchairandwhetheritcouldbeusedinthebeneficiaryshome.However,ourreviewersfoundthattherewasalready documentationinthebeneficiarysfilethatdemonstratedthebeneficiarymetestablishedcriteriaintheapplicableLCD.Further, ourphysicianpaneldeterminedawheelchairwasmedically necessarybecauseofthebeneficiarysfracturedtibia. nRequestsRaiseConcernsAboutBeneficiaryAccessto
o
Denialcause Manualreviewerror AppliedMAO clinicalcriterianotin Medicarecoveragerules AppliedMAO clinicalcriterianotin Medicarecoveragerules Requiredunnecessary documentation PriorAuthorizati
of
Beneficiaryprofile A93-year-oldhadahistoryof epilepsy,earlyonsetAlzheimers, rheumatoidarthritis,chronic backpain,kneeandjointstiffness, andlimitedrange ofmotion. An83-year-old hadprogressivecognitive impairment,progressive declineinwalking,cervicalspine stenosis,andworseningurinary incontinence. A57-year-oldhadmultiplesclerosis, hypertension,bladder dysfunction,tibiafracture,and mobilityissuesrelatedto activitiesofdaily living. OrganizationDenials EI-09-18-00260
al th al al e O
dic wi dic dic ag re,
Servicerequested Durablemeequipment: Hospitalbed rails Durableme equipment: Hydrauliclift Durablemeequipment: Manual wheelchair dicareAdvant NecessaryCa
e y
CaseID D232 D294 D419 omeM Medicall
S ual d) 112 286 641 42
act ate $ $ $1, B|
( m x
Costor esti endi
p
p
A
ResolutionattimeofOIG datarequest Notreversed Notreversed Denialreversedafter provider inquiry
Denialsummary TheMAOdeniedtherequestandcitedinternalclinicalcriteria,statingthatthebeneficiarywasnoteligibletoreceiveawalker becausethebeneficiaryhadalreadyreceivedacanewithinthepast5years.Theinternalclinicalcriteriaconsideredacaneand walkertobesameorsimilardevicesandlimitedbeneficiariestoonesuchdeviceevery5years.However,accordingtoour physicianpanel,acanewasnotstableenoughgiventhebeneficiaryshistoryofpolioandarthritis,fallrisk,andphysical therapynotesthattherightkneebuckledandtherightshoulderwasinpain.Further,ourhealthcarecodingexpertdetermined thattheLCDforwalkersdidnotincludea5-yearrestrictionon morethanoneambulatorydevice. TheMAOdeniedtheconsultationstatingthattherewasno evidencethatthebeneficiaryexperiencedrestrictedbloodfloworablockageofthearteries,asrequiredbyinternalclinicalcriteria. However,theapplicableNCDincludesnosuchrequirementandourphysicianpaneldeterminedthisservicewasmedically necessarygiventhebeneficiarysunstableconditionandlackof sensationbelowthehips. TheMAOdeniedtherequestforafollow-upvisittothephysicianwhotreatedthebeneficiaryintheemergencydepartmentciting Medicaresprohibitionagainstself-referralbyphysicians.However,theMAOdeterminedthattheoriginaldenialwas inappropriatebecauseMedicareself-referralrulesmakean exceptionforemergencydepartmentfollow-upcare. nRequestsRaiseConcernsAboutBeneficiaryAccessto
o
ti
Denialcause AppliedMAOclinicalcriteria notinMedicare coveragerules AppliedMAO clinicalcriterianotin Medicarecoveragerules Determinedthatthe requestdidnotmeet Medicarecoverage criteria PriorAuthoriza
of
Beneficiaryprofile A76-year-oldhadahistoryofjoint pain,post-poliosyndrome,ankle andfootsurgery,andwasat-riskfor falls. An85-year-old hadtype2diabeteswith polyneuropathy(dysfunctionin thenerves)andvenous insufficiency(restrictedblood flowfromthelimbstothe heart). An80-year-oldreceived treatmentintheemergency departmentforafractured humerus. OrganizationDenials EI-09-18-00260
Servicerequested Durablemedicalequipment: Walker Physician services:Interventional radiologyconsultandfollow-upfor peripheralarterial disease Physicianservices:Referral forafollow-upofficevisitafter anemergency departmentvisit. dicareAdvantage NecessaryCare,O
e y
CaseID D460 D320 D300 omeM Medicall
S ual d) 140 096 43
act ate $ $1, B|
( m x
Costor esti endi
p
p
A
d
ResolutionattimeofOIG datarequest Notreversed Denial reversedafterpeertopeer wasconductebyMedical Directorwithadditional information
Denialsummary TheMAOdeniedthefollowupvisitcitinginternalclinicalcriteria,butitdidnotindicatethespecificcriteriathatwerenotmet. However,Medicaredoesnothaveapolicythatexplicitlyaddressesfollowupvisitsaftercancertreatment.Further,ourphysicianpanel determinedthatthevisitwiththeradiationoncologistwasmedicallynecessaryandreasonable,astheremaybepotential cardiac,pulmonaryandothercomplicationsfrombreastradiationandthemostappropriatephysiciantoevaluatethesewouldbethe radiationoncologist,whowouldthenbeabletomakeappropriate treatmentandreferraldecisionsonthepatient'sbehalf. TheMAOdeniedtherequeststatingthatthebeneficiarysmedical recordslackedevidencethatthebeneficiaryexperiencedincontinenceepisodesforatleast2weeksovera6-monthperiod, criteriaestablishedininternalMAOreviewguidelines.Ourreviewersdeterminedthattheservicewasnecessaryand consistentwiththeapplicableNCDbasedondocumentationshowingthatthebeneficiaryhad,foryears,triedmore conservativetreatmentswithnoimprovement. nRequestsRaiseConcernsAboutBeneficiaryAccessto
o
Denialcause AppliedMAOclinicalcriteria notinMedicare coveragerules AppliedMAO clinicalcriterianotin Medicarecoveragerules Required unnecessarydocumentation PriorAuthorizati
of
Beneficiaryprofile A72-year-oldhadahistoryof breastcancersurgeryand partial mastectomy. A74-year-oldwas diagnosedwithfullincontinence offeces.Thebeneficiaryhad involuntarystoolandgasleakage thathadnotimprovedwith otherconservative treatments. OrganizationDenials EI-09-18-00260
Servicerequested Physicianservices:Breast cancerfollow-upvisitwitha radiation oncologist Surgery: Implantationofaneurostimulator devicethatcantreatbowel incontinence dicareAdvantage NecessaryCare,O
e y
CaseID D463 D193 omeM Medicall
S (actual mated) Nocost available xB|44
Costor esti endi
p
p
A
t
aG st d
olutioneofOI areque reverse
esm at ot
Rti d N
Denialsummary TheMAOdeniedtherequeststatingthatthebeneficiarydidnotmeetrequirementsfrominternalclinicalcriteria,suchasproviding theresultsfromanexamthatusesphysicalmanipulationofthejointtotestforpainandconfirmationfromanMRIthatthetendon structuresneededrepair.However,ourphysicianpaneldeterminedthattherewasalreadysufficientclinicalinformationin thebeneficiarysmedicalrecordstojustifythejointreplacementwiththetendonstructurerepairbasedonthebeneficiaryshistory, physicalexam,andx-ray.Further,MedicaredoesnothaveanNCDorLCDspecifictoreverseshoulderarthroplastyandsodoesnot requiretheresultsofthesetestsforapproval. nRequestsRaiseConcernsAboutBeneficiaryAccessto
o
ti
Denialcause AppliedMAOclinicalcriteria notinMedicare coveragerules PriorAuthoriza
of
Beneficiaryprofile A72-year-oldexperiencedpain intherightshoulderforyears. Anx-raydemonstrated osteoarthritisandaphysicalexam indicatedaPopeyedeformity (reflectinganabnormal shorteningordisplacementof thebicepmuscle).Thepatienthad completed6-weeksofphysical therapy. OrganizationDenials EI-09-18-00260
Servicerequested Surgery:Reversetotalarthroplasty -asurgicalprocedurethat repairsandprovidesa prostheticreplacementfor theshoulderjoint(includingthe rotatorcufftearandbiceps tendon) dicareAdvantage NecessaryCare,O
e y
CaseID D207 omeM Medicall
S d 2 3 3
Cost: actualorestimate $10 $7 $7 ndixB|45
e
p
me it alGs ital Gs Ap
Resolutionatti ofOIGdataquestre Denialreversed afterproviderdispute Notreversed (MAOnotedthat reversedthedeniafterreceivingOI datarequest) Notreversed (MAOnotedthatreversedthedeni afterreceivingOI datarequest)
ulesandMAObillingrules Denialsummary TheMAOdeniedpaymentstatingthattherewasnoprior authorizationonfile.Theproviderdisputedthedenial,statingthatnopriorauthorizationwasrequiredforthat serviceandtheMAOagreed. TheMAOdeniedpaymentfortheservice,statingthatitneededdocumentationfromthebeneficiarysprimary insurancecarrier.AfterOIGsdatarequest,theMAOacknowledgedthattherequesteddocumentationwas alreadyincludedintheoriginalclaim. TheMAOdeniedthepayment,statingthatservices receivedduringaninpatientstayrequiredpriorauthorization.AfterOIGsdatarequest,theMAO acknowledgedthatithadapriorauthorizationonfilealready,buthadnotidentifieditbecausenon-behavioral services(e.g.,theechocardiogram)werebilledtoaseparateentityfrombehavioralservices(e.g.,the patientsinpatientpsychiatricadmission). estsRaiseConcernsAboutBeneficiaryAccessto
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arecoverage Denialcause Manualreviewerror MisappliedMAO rule Manualreviewerror Systemprocessing error riorAuthorizationRe
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di n e d m of
entDenialsThatMetMe ServicereceivedBeneficiary profile Imaging:x-raysofA67-year-old shouldersandhadlupusandkneesosteoarthritis. Imaging:MRIofA20-year-oldthelowerspinewasdiagnosed withlumbarspondylosis (degenerationi thebonesofthspine). Imaging:A48-year-old Echocardiogram,awasdiagnosedtypeofimagingwithheart testoftheheartdiseasereceivean echocardiograduringan inpatientpsychiatric admission. dicareAdvantageOrganizationDenials NecessaryCare,OEI-09-18-00260
Paym Case ID D489 D178 D383 omeMe Medically
S d 5 2 2 0
Cost:actualor estimate $ $2 $8 $23 ndixB|46
e
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ti d d d d
natta erseder erse der erseder erse der
oa vvi v vi vvi v vi
ResolutiofOIGd request Denialreafterpro dispute Denialre afterprodispute Denialreafterpro dispute Denialre afterprodispute
Denialsummary MAOdeniedpaymentstatingthatthenebulizerwasbeingrentedfromanoutofnetworkprovider.However, becauseaparticipatingproviderhadissuedareferralforthisservice,theMAOsrequirementsforplandirected carehadbeenmet. MAOdeniedpaymentstatingthattheservicehadnot beenauthorized.Uponreview,theMAOfoundthatanauthorizationhadbeenapprovedbutthattheMAOhad failedtolinktheauthorizationnumbertothepaymentrequest. TheMAOdeniedpaymentstatingthattherequiredpriorauthorizationwasnotonfile.However,theprovider submittedacopyofanauthorizationletterfromtheMAOthatincludedtheserviceanddateofservice. TheMAOdeniedpaymentstatingthatpaymentforthe servicesshouldbebundled.However,aftertheproviderdisputedtheclaim,theMAOlaterdeterminedthese serviceshadinfactbeenbilledcorrectly. estsRaiseConcernsAboutBeneficiaryAccessto
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alcaus mproc pplied mproc mproc mproc uthoriz
Deni Systeerror Misa rule Syste error Systeerror Syste error riorA
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Beneficiaryprofile A65-year-oldhadchronice obstructivepulmonarye disease(achronic inflammatorylungdiseasethat causesobstructed airflowfromthelungs). A68-year-old usesawheelchair. s:A58-year-oldnthadskincancer ofthenose. s:A73-year-old receivedcriticalcareservices fromaphysician. OrganizationDenialsof EI-09-18-00260
Servicereceived Durablemedicalequipment:Hom nebulizerrental(nebulizerschang medicationfromliquidtomist) Durablemedical equipment:Wheelchairrental PhysicianserviceRadiationtreatme consultation Physicianservice Hospitalvisitforrespiratoryfailure dicareAdvantage NecessaryCare,O
e y
CaseID D019 D024 D073 D096 omeM Medicall
S d 4 1 0 3
Cost:actualor estimate $11 $8 $5 $4,04 ndixB|47
e
p
me ital Gs ital Gs it al Gs Ap
ResolutionattiofOIGdata request Denialreversedafterprovider dispute Notreversed (MAOnotedthatreversedthedeni afterreceivingOI datarequest) Notreversed (MAOnotedthatreversedthedeni afterreceivingOI datarequest) Notreversed (MAOnotedthat reversedthedeni afterreceivingOI datarequest)
Denialsummary TheMAOdeniedpaymentforthevisit,statingthatnopriorauthorizationwasinplacefortheout-of-network provider.Apriorauthorizationhadbeenapprovedfortheprocedurebutlistedadifferent,thoughrelated, procedurecodethantheoneincludedontheclaim.Theproviderresubmittedtheclaimshowingtheexisting priorauthorization.TheMAOacknowledgedthateitherprocedurecodecouldhavebeenusedtopaytheclaim andthattheoriginalclaimwasdeniedinerror. TheMAOdeniedthepaymentstatingthattherewasno priorauthorizationonfile.AfterOIGsdatarequest,theMAOacknowledgedthatapriorauthorizationwasnot neededbecausetheproviderwasin-networkandhadbeenmarkedoutofnetworkduetoamanualerror.The MAOreversedthedenialandpaidtheprovider. TheMAOdeniedthepaymentforlackofprior authorization.Typically,theMAOrequiredabeneficiarytoreceiveapriorauthorizationtouseanon-contracted provider.However,becausethebeneficiarywasinanin-networkskillednursingfacility,theclaimmettheMAO andCMSrequirementforplandirectedcareand,therefore,nopriorauthorizationwasrequired. TheMAOdeniedpaymentfortheprocedurestatingthattheservicewasnotcovered.However,theMAOsclaims analystincorrectlydeniedtheentireclaim,ratherthan denyingseverallineitemsthatwerenoncoveredservices.TheMAOpaidtheclaimafteritdiscoveredtheerror. estsRaiseConcernsAboutBeneficiaryAccessto
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Denialcause Systemprocessingerror Manualreviewerro Manualreviewerro MisappliedMAO rule Manualreviewerro riorAuthorizationR
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Beneficiaryprofile s:A73-year-oldwithglaucoma receivedanophthalmological exam. s:A57-year-old visitedthedoctorforasinus infection. s:An85-year-old wasbeinghetreatedina skillednursingfacility. A72-year-oldhadacancerous breasttumor. OrganizationDenialsof EI-09-18-00260
Servicereceived PhysicianserviceEyeexamand treatment Physicianservice Officevisit Physicianservice Treatmentofchroniculceront foot Surgery:Breastreconstruction surgery dicareAdvantage NecessaryCare,O
e y
CaseID D119 D177 D187 D385 omeM Medicall
S d 5 1 2
Cost:actualor estimate $1,98 $40 $50 ndixB|48
e
p
me it alGs Ap
ResolutionattiofOIGdata request Denialreversedafterprovider dispute Notreversed (MAOnotedthat reversedthedeniafterreceivingOI datarequest) Notreversed
Denialsummary TheMAOdeniedpaymentfortheprocedurestatingthattheclaimwassubmittedtoolate.However,theprovider submittedevidencethattheinvoicehadbeenpreviouslysubmittedtotheMAO. TheMAOdeniedpaymentfortheservice,incorrectlystatingthattherewasnopriorauthorizationonfile. Althoughthebeneficiaryhadreceivedpriorauthorizationforthesurgery,theMAOdeniedtheproviderspayment requestsixtimes. TheMAOdeniedpaymentfortwoservicecodes,stating thatthediagnosiscodeswerelistedincorrectlyontheclaim.However,ourreviewersfoundthatofthetwo servicesontheclaim,onewascorrectlycodedandshouldnothavebeendenied. estsRaiseConcernsAboutBeneficiaryAccessto
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De Syserr Syserr Sys err rior
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ServicereceivedBeneficiaryprofile Surgery:IntestinalA67-year-oldobstructionhadlaparoscopic surgerytoremovean obstructioninstomach. Surgery:CardiacAn80-year-oldsurgicalprocedureunderwent surgeryfortheremovaland replacementofadefibrillator,an implanteddevicetohelpcontrol pacingoftheheart. Inpatienthospital:A93-year-old Inpatientadmissionwasdiagnosedandadvancedcarewithcongestive planningheartfailure,anemia,coronary arterydiseaseand myelodysplasticsyndrome(a disorderoftheproductionof bloodcells). dicareAdvantageOrganizationDenialsof NecessaryCare,OEI-09-18-00260
e y
CaseID D090 D128 D454 omeM Medicall
S d 8 6 4 7
Cost:actualor estimate $6,21 $9,51 $27 $2,62 ndixB|49
e
p
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ResolutionattiofOIGdata request Notreversed (MAOnotedthat reversedthedeniafterreceivingOI datarequest) Notreversed Denialreversedafterprovider dispute Notreversed (MAOnotedthatreversedthedeni afterreceivingOI datarequest)
Denialsummary TheMAOdeniedthepaymentbecausetherequestdidnothaverequiredinformation,suchasdischarge summaryandphysiciansnotesandorders.AfterOIGsdatarequest,theMAOacknowledgedthatthe informationhadalreadybeenreceivedandultimatelyreversedthedenial. TheMAOdeniedtheprovidersrequestforinpatientadmissionbasedoninternalclinicalcriteriaandstated thatthepatientdidnotneedaninpatientlevelofcare.TheMAOofferedalowerlevelofcare:observation. However,ourphysicianpaneldeterminedthatthepatientsageandhealthconcerns,suchasafallathome andhipfracture,requiredahigherlevelofcarethananobservationstaywouldhaveprovided. TheMAOdeniedpaymentforanambulancetripbecauseithadexceededcoveragelimitsoncosts.Whenthe providerfiledadispute,theMAOacknowledgedthatthecontracthadbeenupdatedandtheambulanceride shouldhavebeencovered. TheMAOdeniedpaymentfortheambulancetransport forbeingoutofarea.Theproviderresubmittedtheclaimsixtimes.AfterOIGsdatarequest,theMAO determinedthatthecalculationofoutofareawascompletedusinggroundmileageratherthanairmileage and,therefore,wasincorrect. estsRaiseConcernsAboutBeneficiaryAccessto
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Denialcause Manualreviewerro AppliedMAOcliniccriterianotin Medicarecoveragerules Systemprocessingerror Systemprocessing error riorAuthorizationR
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ServicereceivedBeneficiaryprofile Inpatienthospital:A72-year-oldHospitalizationwenttothe afteremergencyemergencyroomroomvisitandwas diagnosedwithapulmonary embolism,ablockageinthe arteriesinthelungs. Inpatienthospital:An80-year-oldInpatientadmissionwenttothe emergencyroom;thepatienthad fallen24hoursbeforeandwas unabletogetup.Beneficiarywas diagnosedwithafractureinthe thighbone(femur). Ambulance:A61-year-oldAmbulanceridetowithsepsiswas ahealthcarefacilitytransportedbyambulancetothe hospital. Ambulance:An80-year-old Ambulancefellathomeandtransporttowastransported hospitalbyambulancetothehospital. dicareAdvantageOrganizationDenialsof NecessaryCare,OEI-09-18-00260
e y
CaseID D183 D440 D116 D375 omeM Medicall
S d 0 4 8 5
Cost:actualor estimate $3 $5 $10 $27 ndixB|50
e
p
me ital Gs it alGs Ap
ResolutionattiofOIGdata request Notreversed Notreversed (MAOnotedthatreversedthedeni afterreceivingOI datarequest) Notreversed (MAOnotedthat reversedthedeniafterreceivingOI datarequest) Denialreversedafterprovider dispute
Denialsummary TheMAOdeniedpaymentstatingthattheapprovedpriorauthorizationonlycoveredchemotherapyand medicationsrelatedtocancertreatmentandnotthelabwork.However,afterreviewingthecasefile,ourhealth carecodingexpertfoundthatavalidpriorauthorization,whichcoveredlabwork,wasineffectonthedateof service. TheMAOdeniedpayment,statingthatithadacapitated contractualagreementfortheprovidertocoverlabwork,meaningtheMAOdidnotneedtopaythehospital separatelyforlabservices.AftertheMAOreceivedOIGsdatarequest,itdiscoveredthatthecapitatedcontractual agreementhadendedpriortothedenialandthusthedenialwasinappropriate. MAOdeniedpayment,incorrectlystatingthattheproviderwasout-of-network.TheMAOsestablished procedurewastomanuallyreviewpaymentrequestsforproviderswithmultipletaxpayeridentificationnumbers, whichdidnothappenforthispaymentrequest.TheMAOinvestigatedthiscaseafterreceivingOIGsdata requestanddetermined,usingthecorrecttaxpayeridentificationnumber,thattheproviderwasin-network. TheMAOdeniedpaymentstatingthatitwasfiledtoolateafterthedateofservice.Theprovidersubmitted evidenceshowingtheclaimhadbeenfiledwithintherequiredtimeframe. estsRaiseConcernsAboutBeneficiaryAccessto
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caus proc proc proc proc horiz
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De Syserr Sys err Syserr Syserr rior
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ServicereceivedBeneficiaryprofile Labtests:A53-year-oldCollectionofbloodwasdiagnosed sample(bloodwithmultipledraw)myeloma,atype ofcancer. Labtests:LabworkA70-year-old usingabloodwithsamplelymphedema receivedlaboratorywork onabloodsample. Therapy:PhysicalAn83-year-oldtherapyhadissueswith gaitandmobilityfollowinga stroke. Therapy:HomeA91-year-oldskillednursingvisitreceivedahome andphysicalskillednursingtherapyevaluationvisitandphysical therapyevaluation. dicareAdvantageOrganizationDenialsof NecessaryCare,OEI-09-18-00260
e y
CaseID D060 D135 D444 D103 omeM Medicall
S d 8 6 5 6
Cost:actualor estimate $66 $33 $2 $6 ndixB|51
e
p
me ital Gs it alGs Ap
ResolutionattiofOIGdata request Denialreversedafterprovider dispute Denialreversed afterproviderdispute Notreversed (MAOnotedthatreversedthedeni afterreceivingOI datarequest) Notreversed (MAOnotedthat reversedthedeniafterreceivingOI datarequest)
Denialsummary TheMAOdeniedpaymentstatingthatnopriorauthorizationwasonfile.Theproviderdisputedthe denialandsubmittedascreenshotdemonstratingthatpriorauthorizationhadpreviouslybeenobtainedforthe dateofservice.TheMAOacknowledgedanerrorinwhichthenumberofauthorizeddayswasnotbeing recognizedinitssystem. MAOdeniedpaymentstatingtherewasnoprior authorizationonfile.TheproviderdisputedthedenialandincludedascreenshotdemonstratingthattheMAO hadgrantedapriorauthorizationforthebilledclaim.TheMAOindicatedthatthedenialresultedfromhuman errortheclaimprocessordidnotrecognizethattherewasanauthorizationonfile. MAOdeniedpaymentstatingtherewasnoprior authorizationonfile.However,afterOIGsdatarequest,theMAOfoundthatapriorauthorizationhadpreviously beenextendedtocoverthedateofservice,sotheclaimshouldhavebeenapproved. MAOdeniedpartoftheclaimasaduplicateservice,citingeditsfromtheNationalCorrectCodingInitiative. AfterOIGsdatarequest,theMAOindicatedthattheedithadbeenincorrectlyappliedbecausetheserviceswere renderedbyphysicianswithdifferentsubspecialties. estsRaiseConcernsAboutBeneficiaryAccessto
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sing erro erro atth tmerage onR
Denialcause Systemproceserror Manualreview Manualreview Incorrectlydeterminedth requestdidnoMedicarecove criteria riorAuthorizati
P
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Servicereceived Radiationtreatment: IntensityModulated RadiationTreatmentDeliver (atypeofradiatiotherapytotreat cancer) Radiation treatment:DeliveofRadiation treatment Chiropractic: Chiropracticmanipulative treatment Othertest:Electrocardio-gra aprocedurethatrecordselectrical signalsfromtheheart dicareAdvantage NecessaryCare,O
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CaseID D441 D442 D433 D435 omeM Medicall
S APPENDIX C
Characteristics of Sampled MAOs
The 15 MAOs included in this review varied in size, enrolling between 165,000 and 5.9
million Medicare beneficiaries in 2019. Service areas for these MAOs covered all50
States, the District of Columbia, and five territories (American Samoa, Guam,
the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands.)
MAO Numberofenrolled NumberofStatesor
beneficiariesin2019 territoriesinservicearea
UnitedHealthGroup,Inc. 5,857,700 56
HumanaInc. 3,922,929 52
CVSHealthCorporation 2,249,248 54
KaiserFoundationHealthPlan,Inc. 1,617,713 8
AnthemInc. 1,135,946 56
WellCareHealthPlans,Inc. 532,053 54
BlueCrossBlueShieldofMichigan 520,485 54
CenteneCorporation 259,356 48
InnovaCareInc. 249,523 15
HighmarkHealth 227,298 54
SCANHealthPlan 203,766 1
UPMCHealthSystem 191,460 54
MedicalCardSystem,Inc. 174,157 1
Healthfirst,Inc. 165,266 51
EmblemHealth,Inc. 165,238 54
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 AppendixC|52 APPENDIX D - AGENCY COMMENTS
DATE:  March 24, 2022 
TO:  Suzanne Murrin
Deputy Inspector General for Evaluation and Inspections 
FROM:  Chiquita Brooks-LaSure 
Administrator 
SUBJECT:  Office of Inspector General (OIG) Draft Report: Some Medicare Advantage 
Organization Denials of Prior Authorization Requests Raise Concerns About 
Beneficiary Access to Medically Necessary Care, OEI-09-18-00260 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office of Inspector Generals (OIG) draft report. CMS is committed to its 
oversight and enforcement of the requirements of the Medicare Advantage program.   
Medicare Advantage plans are Medicare-approved managed care plans offered by Medicare 
Advantage Organizations (MAOs), which are private companies, as an alternative to original
Medicare. MAOs must generally cover the same benefits as original Medicare. However, as part 
of the managed care structure, MAOs may apply internal coverage policies that are no more 
restrictive than original Medicares national and local coverage policies to ensure that plan-
covered items and services are medically necessary and appropriately targeted to the 
beneficiarys conditionand diagnostic needs. MAOs are required to establish and maintain 
written standards, such as coverage rules, practice guidelines, payment policies, and utilization 
management policies, that allow for individual medical necessity determinations.   
MAOs must follow national and local Medicare coverage determinations (NCDs and LCDs) and 
coverage guidance specified in original Medicare manuals, if specific guidelines exist for a given 
service. However, in many cases, NCD or LCD requirements are broad enough that an MAO 
may implement additional coverage requirements to better define the need for the service, as 
long as these additional requirements do not violate the requirements of the applicable NCD or 
LCD. Where there are no applicable NCDs or LCDs, MAOs may establish coverage guidelines, 
as long as the MAOs guidelines are supported by medical evidence. Additionally, for services 
that are not subject to existing LCD and NCD requirements, MAOs may apply third-party 
guidelines, such as guidelines used by contractors engaged by the MAO to make coverage 
determinations. 
CMS uses several tools to oversee the Medicare Advantage program and help ensure enrollees 
have adequate access to health care services. For example, CMS conducts annual audits of a
sample of MAOs to evaluate compliance withthe terms of the MAOs contracts withCMS; in
particular, the requirements associated withaccess to medical services, drugs, and other enrollee
protections required by Medicare. CMS also targets audits to areas of concern, suchas service
types witha highrate of denial. CMS notifies plans of noncompliance, suchas whenit believes a
plans coverage is more restrictive thanunder original Medicare and represents a possible barrier
to accessing care. MAOs are required to submit corrective actionplans to address cited
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 AppendixD|53 deficiencies. Plans that are found to have repeated violations are subject to increasing penalties,
including Civil Monetary Penalties, intermediate sanctions (suspensionof payment, enrollment,
and/or marketing activities), and evencontract terminations.
In recent years, CMS has increased the transparency of audit findings by publishing them on the 
Medicare.gov website and developing a publicly available audit annual report with best practices 
MAOs can adopt to continue improving performance. Our oversight efforts are yielding positive 
results, with the average number of issues cited per audit declining approximately 70 percent 
from 2012 to 2019. In addition, CMS has populated information on the Medicare Plan Finder 
website to provide beneficiaries with information on MAO performance. In addition to the Star 
Ratings mentioned in this report, CMS has utilized the enrollment function in Medicare Plan 
Finder to cease enrollment in MAOs that fail to meet certain requirements. In addition, CMS 
continues to examine ways in which we can use technology tools to streamline processes like 
prior authorization to make them less burdensome on patients and providers.  
While the Medicare Advantage payment denial rate is animportant area to continue to monitor
closely, CMS notes that the overall Medicare Advantage payment request denial rate cited by
OIG for 2018 (9.5 percent) is comparable to the original Medicare denial rate during the same
time period.
OIGs recommendations and CMS' responses are below. 
OIG Recommendation 
CMS should issue new guidance on the appropriate use of MAO clinical criteria in medical 
necessity reviews. 
CMS Response 
CMS concurs with this recommendation. CMS plans to issue clarifying guidance regarding 
appropriate use of clinical criteria in medical necessity reviews. 
OIG Recommendation 
CMS should update its audit protocols to address the issues identified in this report, such as 
MAO use of clinical criteria and/or examining particular service types. 
CMS Response 
CMS concurs with this recommendation. CMS will update its audit protocol if changes are 
necessary to align its audit processes with the guidance CMS plans to issue under Recommendation 
1. Similarly, CMS will update its auditor training materials if changes are necessary as a result of
the guidance CMS plans to issue under Recommendation 1.
OIG Recommendation 
CMS should direct MAOs to take additional steps to identify and address vulnerabilities that can 
lead to manual review and system errors. 
CMS Response 
CMS concurs with this recommendation. CMS will direct MAOs to examine their manual review 
and system programming processes and address vulnerabilities that may result ininappropriate 
denials in keeping with clarifying guidance that CMS plans to issue under Recommendation 1. 
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 AppendixD|54 CMS thanks OIG for their efforts on this issue and looks forward to working with OIG on this and 
other issues in the future. 
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcernsAbout
BeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 AppendixD|55 ACKNOWLEDGMENTS AND CONTACT
Acknowledgments
Rosemary Rawlins Bartholomew and Linda Min served as theteam leaders for this
study. Others in the Office ofEvaluation and Inspections who conducted the study
include Camille Harper, EunjiKim, and Ivy Ngo. Office ofEvaluation and Inspections
staff who provided support include Joe Chiarenzelli, Kevin Farber, Robert Gibbons,
and Christine Moritz.
This report was prepared under thedirection of Blaine Collins, Regional Inspector
Generalfor Evaluation and Inspections in the San Francisco regional office and
Abby Amoroso, Deputy RegionalInspector General.
Contact
To obtain additionalinformation concerning this report, contact the Office ofPublic
Affairs at Public.Affairs@oig.hhs.gov. OIG reports and other information can be found
on the OIG website at oig.hhs.gov.
Office ofInspector General
U.S. Department ofHealth and Human Services
330 Independence Avenue, SW
Washington, DC 20201
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaise
ConcernsAboutBeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 AcknowledgmentsandContact|56 ABOUT THE OFFICE OF INSPECTOR GENERAL
The mission ofthe Office ofInspector General(OIG), as mandated by Public Law 95-
452, as amended, is to protect the integrity ofthe Department ofHealth and Human
Services (HHS)programs, as wellas the health and welfare of beneficiaries served by
those programs. This statutory mission is carried out through a nationwide network
ofaudits, investigations, and inspections conducted by the following operating
components:
The Office of Audit Services (OAS) provides auditing services for HHS,
either by conducting audits with its own audit resources or by overseeingauditwork
done by others. Audits examine the performance ofHHSprograms and/or its
grantees and contractors in carrying outtheir respective responsibilities and are
intended to provide independentassessments ofHHSprograms and operations.
These audits help reducewaste, abuse, and mismanagement and promote economy
and efficiency throughout HHS.
The Office of Evaluation and Inspections (OEI) conducts national
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable
information on significant issues. These evaluations focus on preventing fraud, waste,
or abuse and promoting economy, efficiency, and effectiveness ofdepartmental
programs. To promote impact, OEI reports also present practicalrecommendations
for improving program operations.
The Office of Investigations (OI) conducts criminal, civil, and administrative
investigations offraud and misconduct related to HHS programs, operations, and
beneficiaries. With investigators working in all50 States and the District of Columbia,
OI utilizes its resourcesby actively coordinating with the Department of Justice and
other Federal, State, and local lawenforcement authorities. The investigative efforts
ofOI often lead to criminalconvictions, administrative sanctions, and/or civil
monetary penalties.
The Office of Counsel to the Inspector General (OCIG) provides
generallegalservices to OIG, rendering advice and opinions on HHS programs and
operations and providing all legal support for OIGs internaloperations. OCIG
represents OIG in all civiland administrative fraud and abuse cases involving HHS
programs, including False Claims Act, program exclusion, and civilmonetary penalty
cases. In connection with these cases, OCIG also negotiates and monitors corporate
integrity agreements. OCIG rendersadvisory opinions, issuescompliance program
guidance, publishes fraud alerts, and provides other guidance to the health care
industry concerning theanti-kickback statute and other OIG enforcementauthorities.
SomeMedicareAdvantageOrganizationDenialsofPriorAuthorizationRequestsRaiseConcerns
AboutBeneficiaryAccesstoMedicallyNecessaryCare,OEI-09-18-00260 AboutOIG|57