Dive Brief:

• Boston Scientific and the Medical Device Manufacturers Association (MDMA) want regulators to take more steps to ensure Medicare Advantage plans are consistent in their coverage decisions.
• Medicare Advantage plans, which are offered by private insurers that follow rules set by Medicare, can develop coverage criteria in the absence of applicable national and local coverage determinations. The medtech industry has criticized the transparency of the plans.
• Boston Scientific said in a letter that Medicare Advantage plans “do not often provide a clear reason for the denial of coverage, and rarely offer any visibility into the evidence and methodology” and urged the Centers for Medicare and Medicaid Services (CMS) to “consider policies that require greater transparency.”

Dive Insight:

Late last year, the CMS published a proposed rule to increase oversight of Medicare Advantage plans, including changes to prior authorization requirements intended to reduce disruption for patients. Boston Scientific and MDMA laid out their problems with Medicare Advantage plans in letters to Medicare administrator Chiquita Brooks-LaSure.

“Internal criteria are routinely developed by MA plans without clinician or beneficiary input and without any transparency regarding the evidence considered. In fact, coverage policies developed by MA plans are not even easily accessible for patients, providers and the public. This is especially concerning given the growth in MA enrollment, which represented nearly half of all Medicare beneficiaries in 2022 and is expected to exceed 50% in the next year as enrollment trends continue,” MDMA wrote.

The medtech trade group believes Medicare Advantage plans should be bound by the same rules as the CMS and Medicare Administrative Contractors in developing coverage criteria and determining medical necessity. The Office of the Inspector General (OIG) looked at Medicare Advantage plans last year and found some prior authorization requests were inappropriately denied. 

The CMS responded to the OIG report in its proposal, noting that it showed “certain guardrails are needed to ensure that utilization management tools are used, and associated coverage decisions are made, in ways that ensure timely and appropriate access to medically necessary care.” MDMA “strongly supports” plans to explicitly limit the use of prior authorization to confirm the presence of a diagnosis.

Boston Scientific raised concerns with the enforcement of the rules that apply to Medicare Advantage plans. The medtech company applauded the CMS’ work to inform Medicare Advantage plans of their obligations but noted that the plans “still lack incentives to fulfill their obligations without adequate oversight.” Boston Scientific wants the CMS “to leverage its existing resources and add additional data analysis and enforcement actions to help identify and correct coverage and access to care discrepancies.”