# A Medicare Advantage plan's internal coverage criteria

URL: https://docs.healthcare.dev/reference/medicare-advantage/a-medicare-advantage-plan-s-internal-coverage-criteria

```http
GET https://api.healthcare.dev/v1/medicare-advantage/{plan_id}/criteria
```

Pro 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](/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**

```sh
curl "https://api.healthcare.dev/v1/medicare-advantage/H1036/criteria" \
  -H "Authorization: Bearer $HDEV_API_KEY"
```

**TypeScript**

```ts
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**

```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()
```

## Response

The plan's services covered by internal criteria

```json
{
  "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](https://www.rfc-editor.org/rfc/rfc9457)). Branch on `type`, not on `title`. See [Errors](/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. |