I 

118TH CONGRESS 

1ST SESSION H. R. 5213 

To ensure that prior authorization medical decisions under Medicare are 

determined by physicians. 

IN THE HOUSE OF REPRESENTATIVES 

AUGUST 15, 2023 

Mr. GREEN of Tennessee introduced the following bill; which was referred to 

the Committee on Ways and Means, and in addition to the Committee 

on Energy and Commerce, for a period to be subsequently determined by 

the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To ensure that prior authorization medical decisions under 

Medicare are determined by physicians. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Reducing Medically 

5 Unnecessary Delays in Care Act of 2023’’. 

6 SEC. 2. DEFINITIONS. 

7 In this Act: 

8 (1) ADVERSE DETERMINATION.—The term ‘‘ad9 verse determination’’ means a decision by a medicare 


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1 administrative contractor, Medicare Advantage plan, 

2 or prescription drug plan that administers prior au3 thorization programs under the Medicare program 

4 under title XVIII of the Social Security Act or such 

5 plan that the health care services furnished or pro6 posed to be furnished to an individual entitled to 

7 benefits or enrolled under the Medicare program are 

8 not medically necessary, or are experimental or in9 vestigational; and benefit coverage under such pro10 gram or plan for such services is therefore denied, 

11 reduced, or terminated. 

12 (2) AUTHORIZATION.—The term ‘‘authoriza13 tion’’ means a determination by a medicare adminis14 trative contractor, Medicare Advantage plan, or pre15 scription drug plan that administers prior authoriza16 tion programs under the Medicare program under 

17 title XVIII of the Social Security Act or such plan 

18 that a health care service has been reviewed and, 

19 based on the information provided, satisfies the utili20 zation review entity’s requirements for medical ne21 cessity and appropriateness and that payment will 

22 be made under the Medicare program under title 

23 XVIII of the Social Security Act or such plan for 

24 that health care service. 


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1 (3) CLINICAL CRITERIA.—The term ‘‘clinical 

2 criteria’’ means the written policies, written screen3 ing procedures, drug formularies, or lists of covered 

4 drugs, decision rules, decision abstracts, clinical pro5 tocols, practice guidelines, and medical protocols 

6 used by a medicare administrative contractor, Medi7 care Advantage plan, or prescription drug plan to 

8 determine the necessity and appropriateness of 

9 health care services. 

10 (4) FINAL ADVERSE DETERMINATION.—The 

11 term ‘‘final adverse determination’’ means an ad12 verse determination that has been upheld by a medi13 care administrative contractor, Medicare Advantage 

14 plan, or prescription drug plan at the completion of 

15 the contractor’s appeals process. 

16 (5) HEALTH CARE SERVICE.—The term ‘‘health 

17 care service’’ means a health care item, service, pro18 cedure, treatment, or prescription drug provided by 

19 a facility licensed in the State involved or provided 

20 by a doctor of medicine, a doctor of osteopathy, or 

21 a health care professional licensed in such State. 

22 (6) MEDICALLY NECESSARY HEALTH CARE

23 SERVICE.—The term ‘‘medically necessary health 

24 care services’’ means health care services that a pru25 dent physician would provide to a patient for the 


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1 purpose of preventing, diagnosing, or treating an ill2 ness, injury, disease, or its symptoms in a manner 

3 that is— 

4 (A) in accordance with generally accepted 

5 standards of medical practice; 

6 (B) clinically appropriate in terms of type, 

7 frequency, extent, site, and duration; and 

8 (C) not primarily for the economic benefit 

9 of the health plans and purchasers or for the 

10 convenience of the patient, treating physician, 

11 or other health care provider. 

12 (7) MEDICARE ADMINISTRATIVE CON13 TRACTOR.—The term ‘‘medicare administrative con14 tractor’’ means a medicare administrative contractor 

15 with a contract under section 1874A of the Social 

16 Security Act (42 U.S.C. 1395kk–1). 

17 (8) MEDICARE ADVANTAGE PLAN.—The term 

18 ‘‘Medicare Advantage plan’’ means a Medicare Ad19 vantage plan under part C of title XVIII of the So20 cial Security Act. 

21 (9) PREAUTHORIZATION.—The term 

22 ‘‘preauthorization’’— 

23 (A) means the process by which a medicare 

24 administrative contractor, Medicare Advantage 

25 plan, or prescription drug plan determines the 


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1 medical necessity or medical appropriateness of 

2 health care services for which benefits are oth3 erwise provided under the Medicare program 

4 under title XVIII of the Social Security Act or 

5 such plan prior to the rendering of such health 

6 care services, including preadmission review, 

7 pretreatment review, utilization, and case man8 agement; and 

9 (B) includes any requirement that a pa10 tient or health care provider notify the Centers 

11 for Medicare & Medicaid Services prior to pro12 viding a health care service. 

13 (10) PRESCRIPTION DRUG PLAN.—The term 

14 ‘‘prescription drug plan’’ means a prescription drug 

15 plan under part D of title XVIII of the Social Secu16 rity Act. 

17 SEC. 3. CONTRACT REQUIREMENTS FOR PRIOR AUTHOR18 IZATION MEDICAL DECISIONS FOR MEDI19 CARE ADMINISTRATIVE CONTRACTORS, 

20 MEDICARE ADVANTAGE PLANS, AND PRE21 SCRIPTION DRUG PLANS. 

22 Any contract that applies on or after the date that 

23 is 90 days after the date of the enactment of this Act, 

24 between the Secretary of Health and Human Services and 

25 a medicare administrative contractor under section 1874A 


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1 of the Social Security Act, a Medicare Advantage organi2 zation under section 1857 of such Act with respect to the 

3 offering of a Medicare Advantage plan, or a PDP sponsor 

4 under section 1860D–12 of such Act with respect to the 

5 offering of a prescription drug plan shall require such 

6 medicare administrative contractor, Medicare Advantage 

7 plan, or prescription drug plan, respectively, to comply 

8 with each of the following requirements: 

9 (1) MEDICAL NECESSITY.—Any restriction, 

10 preauthorization, adverse determination, or final ad11 verse determination that the medicare administrative 

12 contractor, Medicare Advantage plan, or prescription 

13 drug plan, respectively, places on the provision of a 

14 health care service for the purposes of coverage or 

15 payment of such service under the Medicare pro16 gram under title XVIII of such Act, or under such 

17 plan, shall be based on the medical necessity or ap18 propriateness of such service and on written clinical 

19 criteria. 

20 (2) EVIDENCE-BASED STANDARDS.—If no inde21 pendently developed evidence-based standards exist 

22 for a particular health care service, the medicare ad23 ministrative contractor, Medicare Advantage plan, or 

24 prescription drug plan, respectively, may not deny 

25 coverage of the health care service based solely on 


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1 the grounds that the health care service does not 

2 meet an evidence-based standard. 

3 (3) INPUT FROM PHYSICIANS.—Prior to estab4 lishing, or substantially or materially altering, writ5 ten clinical criteria for purpose of preauthorization 

6 review, the medicare administrative contractor, 

7 Medicare Advantage plan, or prescription drug plan, 

8 respectively, shall obtain input from actively prac9 ticing physicians within the service area where the 

10 written clinical criteria are to be employed. Such 

11 physicians must represent major areas of specialty 

12 and be certified by the boards of the American 

13 Board of Medical Specialties. The medicare adminis14 trative contractor, Medicare Advantage plan, or pre15 scription drug plan shall seek input from physicians 

16 who are not employees of the medicare administra17 tive contractor, Medicare Advantage plan, or pre18 scription drug plan. 

19 (4) WRITTEN CLINICAL CRITERIA.—The medi20 care administrative contractor, Medicare Advantage 

21 plan, or prescription drug plan, respectively, shall 

22 apply written clinical criteria for the purpose of 

23 preauthorization review consistently. Such written 

24 clinical criteria must— 


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1 (A) be based on nationally recognized 

2 standards; 

3 (B) be developed in accordance with the 

4 current standards of national accreditation enti5 ties; 

6 (C) reflect community standards of care; 

7 (D) ensure quality of care and access to 

8 needed health care services; 

9 (E) be evidence based; 

10 (F) be sufficiently flexible to allow devi11 ations from norms when justified on case-by12 case bases; and 

13 (G) be evaluated and updated if necessary 

14 at least annually. 

15 (5) WEBSITE POSTING.—The medicare adminis16 trative contractor, Medicare Advantage plan, or pre17 scription drug plan, respectively, shall make any cur18 rent preauthorization requirements and restrictions 

19 readily accessible on its website to subscribers, 

20 health care providers, and the general public. This 

21 includes the written clinical criteria. Such require22 ments must be described in detail but also in easily 

23 understandable language. 

24 (6) NOTICE REQUIRED FOR NEW REQUIRE25 MENTS OR RESTRICTIONS.—If the medicare adminisVerDate Sep 11 2014 00:44 Sep 12, 2023 Jkt 039200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H5213.IH H5213

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1 trative contractor, Medicare Advantage plan, or pre2 scription drug plan, respectively, decides to imple3 ment a new preauthorization requirement or restric4 tion, or amend an existing requirement or restric5 tion, the medicare administrative contractor, Medi6 care Advantage plan, or prescription drug plan shall 

7 provide contracted health care providers written no8 tice of the new or amended requirement or amend9 ment no less than 60 days before the requirement or 

10 restriction is implemented and shall ensure that the 

11 new or amended requirement has been updated on 

12 the medicare administrative contractor, Medicare 

13 Advantage plan, or prescription drug plan’s website. 

14 (7) AVAILABILITY OF DETERMINATIONS.—The 

15 medicare administrative contractor, Medicare Advan16 tage plan, or prescription drug plan, respectively, 

17 utilizing preauthorization shall make statistics avail18 able regarding preauthorization approvals and deni19 als for coverage or payment of health care services 

20 under the Medicare program under title XVIII of 

21 the Social Security Act or such plan on their website 

22 in a readily accessible format. The medicare admin23 istrative contractor, Medicare Advantage plan, or 

24 prescription drug plan shall include categories for— 

25 (A) physician specialty; 


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1 (B) medication or diagnostic test/proce2 dure; 

3 (C) indication offered; and 

4 (D) reason for denial. 

5 (8) DETERMINATIONS MADE BY PHYSICIANS.— 

6 The medicare administrative contractor, Medicare 

7 Advantage plan, or prescription drug plan, respec8 tively, shall ensure that all preauthorizations and ad9 verse determinations are made by a physician who 

10 possesses a current and valid non-restricted license 

11 to practice medicine in a State, and must be board 

12 certified or eligible in the same specialty as the 

13 health care provider who typically manages the med14 ical condition or disease or provides the health care 

15 service. The physician must make the adverse deter16 mination under the clinical direction of one of the 

17 medicare administrative contractor’s, Medicare Ad18 vantage plan’s, or prescription drug plan’s medical 

19 directors who is responsible for the provision of 

20 health care services and who is licensed in such 

21 State. 

Æ 


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