# Medicare Advantage internal criteria (preview) URL: https://docs.healthcare.dev/datasets/ma-internal-criteria This dataset is built but not released. Until it is, its endpoints answer `503` `dataset-unavailable` and it is not listed in `/v1/datasets`. This page describes how it will work; details may change before release. | | | | --------------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Source | Each Medicare Advantage organization's public posting of its internal coverage criteria, required by [42 CFR 422.101(b)(6)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-C/section-422.101) (CMS-4201-F) | | Source id | `plan-postings` | | Release cadence | Plans revise their policies monthly or so; we check the postings daily and publish a new version when one changes | | License | Facts from public postings federal rules require, with a link to the plan's document; never the plan's documents or criteria text | | Plans | Pro and Team (`403` `plan-upgrade-required` below) | | Endpoints | [`/v1/medicare-advantage/plans`](/reference/medicare-advantage/medicare-advantage-organizations-with-internal-criteria-postings), [`/v1/medicare-advantage/{plan_id}/criteria?code=`](/reference/medicare-advantage/a-medicare-advantage-plan-s-internal-coverage-criteria) | A Medicare Advantage plan has to follow Medicare's coverage rules: statutes, regulations, National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). Where those don't fully establish the criteria for a service, the plan may use **internal coverage criteria** of its own, and it must post them publicly, without a login or paywall. This dataset tells you which services a plan's posting covers that way, the procedure codes it lists, and where the plan's own document is. Look a plan up by Medicare Advantage contract or organization id, optionally for one code: ```sh curl "https://api.healthcare.dev/v1/medicare-advantage/plans" -H "Authorization: Bearer $HDEV_API_KEY" curl "https://api.healthcare.dev/v1/medicare-advantage/unitedhealthcare/criteria?code=91110" \ -H "Authorization: Bearer $HDEV_API_KEY" ``` ```json { "data": { "plan": { "id": "unitedhealthcare", "organization": { "id": "unitedhealthcare", "name": "UnitedHealthcare" }, "contract": null, "applies_to": "all_ma_plans" }, "code": "91110", "disclaimer": "Reference data, not a coverage determination.", "note": "Facts from each Medicare Advantage organization's public posting ...", "pending_review": 0, "criteria": [ { "organization": { "id": "unitedhealthcare", "name": "UnitedHealthcare" }, "service": { "key": "capsule-endoscopy", "policy_id": null, "name": "Capsule Endoscopy" }, "codes": ["91110", "91111", "91112", "91299"], "uses_internal_criteria": { "answer": "yes", "confidence": 0.8, "derivation": "derived", "evidence": [ { "url": "https://www.uhcprovider.com/en/policies-protocols/medicare-advantage-policies/medicare-advantage-medical-policies.html" } ], "as_of": "2026-10-25T05:30:00.000Z" }, "basis": "organization_statement", "criteria_url": "https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-mp/capsule-endoscopy.pdf", "posting_url": "https://www.uhcprovider.com/en/policies-protocols/medicare-advantage-policies/medicare-advantage-medical-policies.html", "effective_date": null, "updated_date": "2026-09-01" } ] } } ``` `plan_id` is a contract (`H1036`) or an organization id from `GET /v1/medicare-advantage/plans`. An organization's posting applies to all its Medicare Advantage plans, so a contract answers with its organization's services (`applies_to: all_ma_plans`). Without `code` you get every service in the posting; with it, the services whose posting lists that code. A code no service lists means only that: the plan may cover it under a policy without a code list, or follow Medicare's own criteria for it. ## The fields | Field | What it is | | -------------------------------- | --------------------------------------------------------------------------------------------------------------- | | `service` | The plan's policy: our stable `key`, the plan's own `policy_id` when it gives one, and its `name` | | `codes` | Procedure codes the posting lists for the service: HCPCS Level II codes and CPT numbers, never CPT descriptions | | `uses_internal_criteria` | `yes` or `no`, as the posting states it, with `derivation`, `confidence`, `evidence` and `as_of` | | `basis` | Where the answer comes from: the organization's statement (`organization_statement`) or a person's check | | `criteria_url` | The plan's document for the service: read it for the criteria themselves | | `posting_url` | The organization's page listing its policies | | `effective_date`, `updated_date` | When the policy's current version took effect, and when the plan last published or reviewed it | | `differs_from_medicare_criteria` | Present only when a person confirmed a difference from an NCD or LCD (below) | We never store or serve the criteria text. The plan's document is the source; we give you the facts to find it and the link. ## How answers are read: `derivation` We read organizations' public policy lists and statement pages, not the policy documents themselves (`basis: organization_statement`): - **`source_stated`** (confidence 1): the organization says plainly that every Medicare Advantage policy it lists is written where Medicare's criteria aren't fully established. - **`derived`** (confidence below 1): the organization says it _may_ apply internal criteria in the policies it lists, without saying which; the plan's document says where they apply. - **`reviewed`**: the posting didn't say, so a person read it (`basis: person_checked_posting`). A policy whose posting doesn't say waits for that person and isn't listed until then; `pending_review` counts those. When the plan changes a policy's entry in its list, we read it afresh. ## `differs_from_medicare_criteria` Where Medicare's own criteria exist for a code, a plan has to follow them. We compare plans' postings with [Medicare coverage](/datasets/medicare-coverage) documents: rules find candidates (for example, a plan says a policy's codes have no Medicare criteria while an LCD lists them, or a code tied to an NCD is under a plan's internal criteria), and **a person reads both documents and decides every one**. Nothing is ever flagged by rules alone, and a candidate is never shown before that review. When the person confirms that the plan's criteria differ from Medicare's for some codes, the service carries: ```json "differs_from_medicare_criteria": [ { "medicare_document": { "id": "L35013", "type": "lcd", "title": "...", "url": "https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=35013&ver=4" }, "codes": ["11720"], "states": ["TX"], "finding": { "answer": "differs", "confidence": 1, "derivation": "reviewed", "evidence": [{ "url": "https://..." }, { "url": "https://www.cms.gov/..." }], "as_of": "2026-10-25T05:30:00.000Z" } } ] ``` It says the two documents differ for those codes where the Medicare document applies (`states`; empty when it is national). It is a comparison of two public documents, not a legal finding or a coverage determination. Its absence means no confirmed difference, not that the criteria match. ## What it is not - **Not a coverage determination** and not prior authorization: whether a member's service is covered depends on their plan and situation. - **Not the criteria.** Read the plan's document (`criteria_url`). - Not every plan. Some organizations publish their criteria only behind a portal that needs accepted terms or a sign-in, or ask not to be crawled; we leave those out rather than work around them. `GET /v1/medicare-advantage/plans` lists the organizations we hold. ## MCP and SDKs - MCP: `check_ma_internal_criteria` with `{ "plan": "H1036", "code": "91110" }`. - TypeScript: `hdev.medicareAdvantage.criteria("H1036", { code: "91110" })`, `hdev.medicareAdvantage.plans()`. - Python: `hdev.medicare_advantage.criteria("H1036", code="91110")`, `hdev.medicare_advantage.plans()`.