A Medicare Advantage plan's internal coverage criteria
GET /v1/medicare-advantage/{plan_id}/criteria
GET https://api.healthcare.dev/v1/medicare-advantage/{plan_id}/criteriaPro plan and up (below: a few preview calls a month, then 403 plan-upgrade-required). Preview: not available yet. Which services a Medicare Advantage plan's public posting covers with its internal coverage criteria (which it may use only where Medicare's own criteria are not fully established), per service (policy): uses_internal_criteria (yes/no), the procedure codes the posting lists (identifiers only), effective and updated dates, and the link to the plan's own document (criteria_url). Never the criteria themselves: read the plan's document. 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. code keeps the services whose posting lists that code. uses_internal_criteria says how it was reached: derivation: source_stated when the plan's posting states it (basis says where), reviewed when a person read a posting that didn't say. differs_from_medicare_criteria appears only after a person compared the plan's document with an applicable NCD, LCD or billing article and confirmed that they differ; it is never set by rules alone. Reference data, not a coverage determination.
Requires an API key: Authorization: Bearer hdev_live_.... See Authentication.
Path parameters
| Name | Type | Required | Description | Example |
|---|---|---|---|---|
plan_id | string | yes | A Medicare Advantage contract (H1036) or an organization id (humana) | H1036 |
Query parameters
| Name | Type | Required | Description | Example |
|---|---|---|---|---|
code | string | no | Only services whose posting lists this procedure code (HCPCS or CPT number) | 91110 |
view | "compact" | "standard" | "full" | no | How much of each record to return (default full). compact: service, uses_internal_criteria, criteria_url, differs_from_medicare_criteria (fewest tokens, for agents). standard: every field except organization. full: every field. | compact |
fields | string | no | Comma-separated fields to return instead of a view. Valid fields: organization, service, codes, uses_internal_criteria, basis, criteria_url, posting_url, effective_date, updated_date, differs_from_medicare_criteria. | service,uses_internal_criteria,criteria_url |
Examples
curl
curl "https://api.healthcare.dev/v1/medicare-advantage/H1036/criteria" \
-H "Authorization: Bearer $HDEV_API_KEY"TypeScript
const res = await fetch("https://api.healthcare.dev/v1/medicare-advantage/H1036/criteria", {
headers: { Authorization: `Bearer ${process.env.HDEV_API_KEY}` },
});
const { data, meta } = await res.json();Python
import os
import requests
res = requests.get("https://api.healthcare.dev/v1/medicare-advantage/H1036/criteria", headers={"Authorization": f"Bearer {os.environ['HDEV_API_KEY']}"})
body = res.json()Try it
Response
The plan's services covered by internal criteria
{
"data": {
"plan": {
"id": "string",
"organization": {
"id": null,
"name": null
},
"contract": "string",
"applies_to": "all_ma_plans"
},
"code": "string",
"disclaimer": "Reference data, not a coverage determination.",
"note": "string",
"pending_review": 1,
"criteria": [
{
"organization": null,
"service": null,
"codes": [
null
],
"uses_internal_criteria": null,
"basis": null,
"criteria_url": "string",
"posting_url": "string",
"effective_date": "2026-10-01",
"updated_date": "2026-10-01",
"differs_from_medicare_criteria": [
null
]
}
]
},
"meta": {
"source": "cms-icd10",
"data_version": "2026.1",
"retrieved_at": "2026-10-24T12:00:00Z",
"license": "Public domain (CMS). Reference data, not medical advice."
},
"links": {
"self": "/v1/medicare-advantage/H1036/criteria",
"next": null
}
}Fields
| Field | Type | Always present | Description |
|---|---|---|---|
plan | MaPlanRef | yes | |
code | string | null | yes | The procedure code asked about, if any |
disclaimer | "Reference data, not a coverage determination." | yes | |
note | string | yes | How to read these answers (show it with them) |
pending_review | integer | yes | Policies in the posting we hold but whose answer waits for a person to check it (not listed below) |
criteria | MaCriteriaEntry[] | yes | One per service (policy), by service name |
Errors
Errors are application/problem+json (RFC 9457). Branch on type, not on title. See Errors.
| Status | type | When |
|---|---|---|
| 400 | invalid-request | A parameter or the body failed validation; errors lists each field. |
| 401 | unauthorized | Missing, malformed or revoked API key. |
| 403 | plan-upgrade-required | The plan doesn't include this feature; required_plan names the plan that does. |
| 404 | not-found | No record with that id (retired records are still returned). |
| 429 | rate-limited / quota-exceeded | Too many requests per second (retry after Retry-After), or the monthly quota is used up. |
| 503 | dataset-unavailable / unavailable | The dataset has no published version yet, or the service is degraded. |