Questions & answers · Health insurance
Can a Medicare Advantage plan use an algorithm to deny my care?
Health insuranceDeniedChecked Nov 6, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: GovInfo · 42 CFR 422.101 Requirements relating to basic benefits · § 422.101(c)(1) View original ↗
In short
- The rule does not say the word algorithm.
- A plan has to use Medicare rules and your medical records.
- It can't deny basic care on criteria Medicare doesn't set.
What this means
The federal rule for Medicare Advantage plans does not use the word "algorithm". It does say what a plan must base a decision on [1]. The plan must use the coverage rules in the Medicare regulation. It can't deny basic benefits on criteria that those rules do not set [1]. It must ask if the care is reasonable and necessary under Medicare law [1]. It must use your medical history and your doctor's advice and notes [1]. Where right, the plan's medical director must take part [1].
The sources do not say what software a plan may use as a tool.
Your next step
Ask your plan which coverage criteria it used. The rule says it may not deny basic benefits on criteria that paragraphs (b) or (c) do not specify [1]. The sources give no deadline.
Check it yourself
Your plan's denial notice is the paper to read. How a plan uses software is "Don't know yet" from the sources.
Where this comes from (1)
[1] GovInfo · 42 CFR 422.101 Requirements relating to basic benefits · § 422.101(c)(1) · checked 2026-11-06
MA organizations must make medical necessity determinations based on all of the following: ( A ) Coverage and benefit criteria as specified at paragraphs (b) and (c) of this section and may not deny coverage for basic benefits based on coverage criteria not specified in paragraph (b) or (c) of this section. ( B ) Whether the provision of items or services is reasonable and necessary under section 1862(a)(1) of the Ac…
How we found this
We matched your question to 1 official source, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.
What we don’t know yet
Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.
Every answer is checked against the official rule it quotes.
Information only — not legal advice. Your plan, insurer or agency decides.
This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.
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