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Condensed Appeals & Grievances Guidance

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Role of the Medical Director

  • All plans must employ a medical director who is responsible for ensuring the clinical accuracy of all coverage decisions involving medical necessity.
  • CMS does not; however, expect that the medical director review every medical necessity decision.
  • The plan must establish a process for when a medical director must be involved.

QUESTION FROM THE AUDIENCE

  • Does a Medical Director or Physician needs to see all denied coverage determinations with lack of medical necessity?
  • Can it be a Pharmacist?

ANSWER TO QUESTION

Who Must Review an Initial Determination

If a plan initially reviews a request and expects to issue a partially or fully adverse decision based on medical necessity, the review must be completed by a physician, as defined in section 1861(r) of the Act, or other appropriate healthcare professional who has:

  • Sufficient medical and other expertise;
  • Knowledge of the Medicare coverage criteria; and
  • A current and unrestricted license to practice within the scope of his or her profession in a State, Territory, Commonwealth of the United States (that is, Puerto Rico), or the District of Columbia.

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