Effective November 12, 2026, requests to reconsider adverse Medicare-covered inpatient and post-acute care determinations must be submitted through the Medicare appeals process
This change applies to Medicare Advantage and Dual Special Needs Plan (D-SNP) physical health inpatient and post-acute care authorization determinations. While educational peer-to-peer (P2P) discussions remain available, they cannot be used to request reconsideration of an adverse determination or change a determination outcome. Continued submission of complete and clinically relevant documentation with authorization requests remains important to support medical necessity and appropriate care.
How to request a reconsideration
If you disagree with an adverse inpatient or post-acute care authorization determination:
- Submit a request for reconsideration using the instructions included in the adverse determination letter.
- Include any additional supporting clinical documentation with your reconsideration request.
Educational P2P discussions remain available
P2P discussions remain available regarding:
- The patient’s clinical condition.
- The treatment plan.
- Medical necessity criteria.
- Clinical information submitted for review.
- The rationale for the determination.
P2P discussions support physician-to-physician clinical dialogue and are educational in nature. They do not constitute a request for reconsideration. Physicians, practitioners and other providers who disagree with an adverse determination must submit a reconsideration request through the Medicare appeals process.
Why this change is being made
This change aligns the reconsideration process for Medicare adverse determinations with Centers for Medicare & Medicaid Services (CMS) guidelines. Reconsiderations are reviewed by a physician not involved in the original determination to ensure an independent and objective review.
Regulatory requirements
Coverage determinations and appeals will continue to follow applicable Medicare coverage criteria and regulatory requirements, including:
- Organization determinations: 42 CFR 422.566 and 42 CFR 422.101
- Appeals: 42 CFR 422.578, 42 CFR 422.582 and 42 CFR 422.584, 42 CFR §422.590
- Applicable Integrated Plans (D-SNPs): 42 CFR 422.629 through 42 CFR 422.634
This information applies to Physicians and Practitioners, Independent Practice Associations (IPAs), Hospitals, and Ancillary Providers
