I
119THCONGRESS
1
STSESSION H. R. 2433
To ensure that prior authorization medical decisions under Medicare are
determined by physicians.
IN THE HOUSE OF REPRESENTATIVES
MARCH27, 2025
Mr. G
REENof Tennessee (for himself, Mr. MURPHY, Ms. SCHRIER, Mr.
J
OYCEof Pennsylvania, Mr. MCCORMICK, Mr. HARRISof Maryland, Mr.
B
URCHETT, Mr. BABIN, Mrs. MILLER-MEEKS, and Mr. KENNEDYof
Utah) introduced the following bill; which was referred to the Committee
on Ways and Means, and in addition to the Committee on Energy and
Commerce, for a period to be subsequently determined by the Speaker,
in each case for consideration of such provisions as fall within the juris-
diction of the committee concerned
A BILL
To ensure that prior authorization medical decisions under
Medicare are determined by physicians.
Be it enacted by the Senate and House of Representa-1
tives of the United States of America in Congress assembled, 2
SECTION 1. SHORT TITLE. 3
This Act may be cited as the ‘‘Reducing Medically 4
Unnecessary Delays in Care Act of 2025’’. 5
SEC. 2. DEFINITIONS. 6
In this Act: 7
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(1) ADVERSE DETERMINATION .—The term ‘‘ad-1
verse determination’’ means a decision by a medicare 2
administrative contractor, Medicare Advantage plan, 3
or prescription drug plan that administers prior au-4
thorization programs under the Medicare program 5
under title XVIII of the Social Security Act or such 6
plan that the health care services furnished or pro-7
posed to be furnished to an individual entitled to 8
benefits or enrolled under the Medicare program are 9
not medically necessary, or are experimental or in-10
vestigational; and benefit coverage under such pro-11
gram or plan for such services is therefore denied, 12
reduced, or terminated. 13
(2) A
UTHORIZATION.—The term ‘‘authoriza-14
tion’’ means a determination by a medicare adminis-15
trative contractor, Medicare Advantage plan, or pre-16
scription drug plan that administers prior authoriza-17
tion programs under the Medicare program under 18
title XVIII of the Social Security Act or such plan 19
that a health care service has been reviewed and, 20
based on the information provided, satisfies the utili-21
zation review entity’s requirements for medical ne-22
cessity and appropriateness and that payment will 23
be made under the Medicare program under title 24
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XVIII of the Social Security Act or such plan for 1
that health care service. 2
(3) C
LINICAL CRITERIA.—The term ‘‘clinical 3
criteria’’ means the written policies, written screen-4
ing procedures, drug formularies, or lists of covered 5
drugs, decision rules, decision abstracts, clinical pro-6
tocols, practice guidelines, and medical protocols 7
used by a medicare administrative contractor, Medi-8
care Advantage plan, or prescription drug plan to 9
determine the necessity and appropriateness of 10
health care services. 11
(4) F
INAL ADVERSE DETERMINATION .—The 12
term ‘‘final adverse determination’’ means an ad-13
verse determination that has been upheld by a medi-14
care administrative contractor, Medicare Advantage 15
plan, or prescription drug plan at the completion of 16
the contractor’s appeals process. 17
(5) H
EALTH CARE SERVICE.—The term ‘‘health 18
care service’’ means a health care item, service, pro-19
cedure, treatment, or prescription drug provided by 20
a facility licensed in the State involved or provided 21
by a doctor of medicine, a doctor of osteopathic med-22
icine, or a health care professional licensed in such 23
State. 24
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(6) MEDICALLY NECESSARY HEALTH CARE 1
SERVICE.—The term ‘‘medically necessary health 2
care services’’ means health care services that a pru-3
dent physician would provide to a patient for the 4
purpose of preventing, diagnosing, or treating an ill-5
ness, injury, disease, or its symptoms in a manner 6
that is— 7
(A) in accordance with generally accepted 8
standards of medical practice; 9
(B) clinically appropriate in terms of type, 10
frequency, extent, site, and duration; and 11
(C) not primarily for the economic benefit 12
of the health plans and purchasers or for the 13
convenience of the patient, treating physician, 14
or other health care provider. 15
(7) M
EDICARE ADMINISTRATIVE CON -16
TRACTOR.—The term ‘‘medicare administrative con-17
tractor’’ means a medicare administrative contractor 18
with a contract under section 1874A of the Social 19
Security Act (42 U.S.C. 1395kk–1). 20
(8) M
EDICARE ADVANTAGE PLAN .—The term 21
‘‘Medicare Advantage plan’’ means a Medicare Ad-22
vantage plan under part C of title XVIII of the So-23
cial Security Act. 24
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(9) P REAUTHORIZATION.—The term 1
‘‘preauthorization’’— 2
(A) means the process by which a medicare 3
administrative contractor, Medicare Advantage 4
plan, or prescription drug plan determines the 5
medical necessity or medical appropriateness of 6
health care services for which benefits are oth-7
erwise provided under the Medicare program 8
under title XVIII of the Social Security Act or 9
such plan prior to the rendering of such health 10
care services, including preadmission review, 11
pretreatment review, utilization, and case man-12
agement; and 13
(B) includes any requirement that a pa-14
tient or health care provider notify the Centers 15
for Medicare & Medicaid Services prior to pro-16
viding a health care service. 17
(10) P
RESCRIPTION DRUG PLAN .—The term 18
‘‘prescription drug plan’’ means a prescription drug 19
plan under part D of title XVIII of the Social Secu-20
rity Act. 21
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SEC. 3. CONTRACT REQUIREMENTS FOR PRIOR AUTHOR-1
IZATION MEDICAL DECISIONS FOR MEDI-2
CARE ADMINISTRATIVE CONTRACTORS, 3
MEDICARE ADVANTAGE PLANS, AND PRE-4
SCRIPTION DRUG PLANS. 5
Any contract that applies on or after the date that 6
is 90 days after the date of the enactment of this Act, 7
between the Secretary of Health and Human Services and 8
a medicare administrative contractor under section 1874A 9
of the Social Security Act, a Medicare Advantage organi-10
zation under section 1857 of such Act with respect to the 11
offering of a Medicare Advantage plan, or a PDP sponsor 12
under section 1860D–12 of such Act with respect to the 13
offering of a prescription drug plan shall require such 14
medicare administrative contractor, Medicare Advantage 15
plan, or prescription drug plan, respectively, to comply 16
with each of the following requirements: 17
(1) M
EDICAL NECESSITY .—Any restriction, 18
preauthorization, adverse determination, or final ad-19
verse determination that the medicare administrative 20
contractor, Medicare Advantage plan, or prescription 21
drug plan, respectively, places on the provision of a 22
health care service for the purposes of coverage or 23
payment of such service under the Medicare pro-24
gram under title XVIII of such Act, or under such 25
plan, shall be based on the medical necessity or ap-26
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propriateness of such service and on written clinical 1
criteria. 2
(2) E
VIDENCE-BASED STANDARDS.—If no inde-3
pendently developed evidence-based standards exist 4
for a particular health care service, the medicare ad-5
ministrative contractor, Medicare Advantage plan, or 6
prescription drug plan, respectively, may not deny 7
coverage of the health care service based solely on 8
the grounds that the health care service does not 9
meet an evidence-based standard. 10
(3) I
NPUT FROM PHYSICIANS .—Prior to estab-11
lishing, or substantially or materially altering, writ-12
ten clinical criteria for purpose of preauthorization 13
review, the medicare administrative contractor, 14
Medicare Advantage plan, or prescription drug plan, 15
respectively, shall obtain input from actively prac-16
ticing physicians within the service area where the 17
written clinical criteria are to be employed. Such 18
physicians must represent major areas of specialty 19
and be certified by the boards of the American 20
Board of Medical Specialties or the American Osteo-21
pathic Association. The medicare administrative con-22
tractor, Medicare Advantage plan, or prescription 23
drug plan shall seek input from physicians who are 24
not employees of the medicare administrative con-25
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tractor, Medicare Advantage plan, or prescription 1
drug plan. 2
(4) W
RITTEN CLINICAL CRITERIA .—The medi-3
care administrative contractor, Medicare Advantage 4
plan, or prescription drug plan, respectively, shall 5
apply written clinical criteria for the purpose of 6
preauthorization review consistently. Such written 7
clinical criteria must— 8
(A) be based on nationally recognized 9
standards; 10
(B) be developed in accordance with the 11
current standards of national accreditation enti-12
ties; 13
(C) reflect community standards of care; 14
(D) ensure quality of care and access to 15
needed health care services; 16
(E) be evidence based; 17
(F) be sufficiently flexible to allow devi-18
ations from norms when justified on case-by- 19
case bases; and 20
(G) be evaluated and updated if necessary 21
at least annually. 22
(5) W
EBSITE POSTING.—The medicare adminis-23
trative contractor, Medicare Advantage plan, or pre-24
scription drug plan, respectively, shall make any cur-25
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rent preauthorization requirements and restrictions 1
readily accessible on its website to subscribers, 2
health care providers, and the general public. This 3
includes the written clinical criteria. Such require-4
ments must be described in detail but also in easily 5
understandable language. 6
(6) N
OTICE REQUIRED FOR NEW REQUIRE -7
MENTS OR RESTRICTIONS .—If the medicare adminis-8
trative contractor, Medicare Advantage plan, or pre-9
scription drug plan, respectively, decides to imple-10
ment a new preauthorization requirement or restric-11
tion, or amend an existing requirement or restric-12
tion, the medicare administrative contractor, Medi-13
care Advantage plan, or prescription drug plan shall 14
provide contracted health care providers written no-15
tice of the new or amended requirement or amend-16
ment no less than 60 days before the requirement or 17
restriction is implemented and shall ensure that the 18
new or amended requirement has been updated on 19
the medicare administrative contractor, Medicare 20
Advantage plan, or prescription drug plan’s website. 21
(7) A
VAILABILITY OF DETERMINATIONS .—The 22
medicare administrative contractor, Medicare Advan-23
tage plan, or prescription drug plan, respectively, 24
utilizing preauthorization shall make statistics avail-25
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able regarding preauthorization approvals and deni-1
als for coverage or payment of health care services 2
under the Medicare program under title XVIII of 3
the Social Security Act or such plan on their website 4
in a readily accessible format. The medicare admin-5
istrative contractor, Medicare Advantage plan, or 6
prescription drug plan shall include categories for— 7
(A) physician specialty; 8
(B) medication or diagnostic test/proce-9
dure; 10
(C) indication offered; and 11
(D) reason for denial. 12
(8) D
ETERMINATIONS MADE BY PHYSICIANS .— 13
The medicare administrative contractor, Medicare 14
Advantage plan, or prescription drug plan, respec-15
tively, shall ensure that all preauthorizations and ad-16
verse determinations are made by a physician who 17
possesses a current and valid non-restricted license 18
to practice medicine in a State, and must be board 19
certified or eligible under the rules and guidelines of 20
the American Board of Medical Specialties or Amer-21
ican Osteopathic Association in the same specialty 22
as the health care provider who typically manages 23
the medical condition or disease or provides the 24
health care service. The physician must make the 25
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adverse determination under the clinical direction of 1
one of the medicare administrative contractor’s, 2
Medicare Advantage plan’s, or prescription drug 3
plan’s medical directors who is responsible for the 4
provision of health care services and who is licensed 5
in such State. 6
Æ
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