The coverage-criteria rule every MA plan has to follow
Checked against the current rules on September 18, 2026.
This is the single most-cited rule in a Medicare Advantage appeal: a plan has to cover at least what Traditional Medicare covers, and can't quietly apply a stricter standard of its own.
Source: 42 CFR Part 422 — coverage-criteria and Part B drug sections cross-referenced by Subpart M.
A Medicare Advantage plan must provide all coverage required under Traditional Medicare's own national coverage rules (Medicare statute, NCDs, and general coverage guidelines) — it cannot deny something Traditional Medicare would cover.42 CFR 422.101
A 2024 final rule (CMS-4201-F) tightened this further: when Medicare's own coverage rules don't fully cover a situation, a plan MAY create its own internal coverage criteria — but only if they're publicly posted, based on current clinical evidence, and the plan explains the evidence behind them. A plan can't rely on a secret or unsupported internal policy to deny care.Federal Register
What this means for your appeal
When a denial cites the plan's own "internal guideline" or "medical policy" rather than a Medicare rule by name, it's fair — and often effective — to ask the plan to show that the policy is publicly posted and cites current clinical evidence, exactly as the 2024 rule requires.
A plan can never use its own internal criteria to be MORE restrictive than an area where Medicare's own coverage rules are already clear and complete — internal criteria are only allowed to fill genuine gaps, not to override a settled Medicare rule.
This is the single rule most of CaseWhy Appeals' own explanations rely on first: it's the reason a plan's stated reason for denial can be checked against a real, external standard rather than just taken at face value.
This same section also covers Part B drugs, requiring a Medicare Advantage plan to cover the drugs Traditional Medicare's Part B would cover, on the same basic terms — a denial for a Part B drug is checked against this rule the same way a service denial is.
This rule is why a family researching their own denial can meaningfully check a plan's reasoning against Traditional Medicare's own published coverage rules — the comparison itself is exactly what the law requires the plan to meet.
Sources — last checked September 18, 2026
- 42 CFR 422.101as of September 18, 2026
- Federal Register
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By CaseWhy Appeals editorial. See how this content is produced. Not legal advice. Not affiliated with or endorsed by Medicare, CMS, or any health plan. A product of CaseWhy LLC.
