Check MA internal criteria (preview)

A Medicare Advantage plan has to follow Medicare's own coverage rules (NCDs and LCDs). Where those don't fully establish the criteria for a service, the plan may use internal criteria of its own, and must post them. This recipe tells you whether a plan's posting covers a code that way, and where the plan's document is.

1. Find the planCopy Anchor Link

curl "https://api.healthcare.dev/v1/medicare-advantage/plans?q=humana" \
  -H "Authorization: Bearer $HDEV_API_KEY"

plan_id is a Medicare Advantage contract (H1036) or an organization id from this list. A contract answers with its organization's posting, which applies to all its plans.

2. Ask about a codeCopy Anchor Link

curl "https://api.healthcare.dev/v1/medicare-advantage/H1036/criteria?code=91110" \
  -H "Authorization: Bearer $HDEV_API_KEY"

{
  "data": {
    "plan": { "id": "H1036", "applies_to": "all_ma_plans", "...": "..." },
    "code": "91110",
    "disclaimer": "Reference data, not a coverage determination.",
    "pending_review": 0,
    "criteria": [
      {
        "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://..." }],
          "as_of": "2026-10-25T05:30:00.000Z"
        },
        "basis": "organization_statement",
        "criteria_url": "https://...",
        "posting_url": "https://...",
        "updated_date": "2026-09-01"
      }
    ]
  }
}

TypeScript

import { HealthcareDev } from "@healthcare.dev/sdk";

const hdev = new HealthcareDev();

const { data } = await hdev.medicareAdvantage.criteria("H1036", { code: "91110" });
for (const c of data.criteria) {
  const { answer, derivation, confidence } = c.uses_internal_criteria;
  console.log(c.service.name, answer, derivation, confidence, c.criteria_url);
}
console.log(data.disclaimer);

Python

from healthcare_dev import HealthcareDev

hdev = HealthcareDev()

ma = hdev.medicare_advantage.criteria("H1036", code="91110")["data"]
for c in ma["criteria"]:
    u = c["uses_internal_criteria"]
    print(c["service"]["name"], u["answer"], u["derivation"], u["confidence"], c["criteria_url"])
print(ma["disclaimer"])

Ask an agentCopy Anchor Link

Does Medicare Advantage contract H1036 use internal coverage criteria for code 91110? Link the plan's policy document, say how sure the answer is, and remind me this isn't a coverage determination.

The agent uses check_ma_internal_criteria.

Read the answerCopy Anchor Link

• uses_internal_criteria.answer is yes or no, as the plan's posting states it.
• derivation: source_stated (confidence: 1) when the organization says plainly that every policy it lists is written where Medicare's criteria aren't fully established; derived (confidence below 1) when it says it may apply internal criteria in the policies it lists, without saying which, so the plan's document says where they apply; reviewed when a person read the posting. Policies waiting for that person aren't listed; pending_review counts them.
• criteria_url is the plan's own document: read it for the criteria. We never serve the criteria text.
• differs_from_medicare_criteria appears only when a person confirmed a difference from an NCD or LCD.
• No service listing the code means only that: the plan may cover it under a policy without a code list, or follow Medicare's own criteria. Check Medicare coverage for those.

What it is notCopy Anchor Link

Reference data, not a coverage determination. Codes are served as numbers only, never with CPT descriptions.