Wiki Medicare vs. Medicare Advantage

[quinn1234@tampabay.rr.com]

Whose coverage guidelines would take precedence between Medicare (MCR) NCD and a Medicare Advantage (MA) clinical policy, where the MA's policy was more restrictive? For example: If MCR guideline allowed for treating a certain condition, but the MA plan's guidelines require additional criteria needed to meet satisfaction, can they still deny a claim or do they have to follow MCR's guidelines?

 

[MH3550]

Medicare Advantage plans have to follow CMS guidelines unless you have a contract that states differently. I would check out this link from Corrohealth. It talks about CMS 4201 final rule. Basically, Medicare is cracking down on Medicare Advantage plans not following their guidelines like they are supposed to. https://issuu.com/para-hcfs/docs/corrohealth_weekly_ejournal_august_30_2023/13. We reference this in appeals and have had some success.