If you're enrolled in a Medicare Advantage plan, there's a good chance your insurer is using artificial intelligence to decide whether your doctor's treatment recommendation gets approved — or denied. Representatives Greg Landsman of Ohio and Suzan DelBene of Washington have introduced legislation in the House aimed at reining in this practice, arguing that AI-driven prior authorization systems are systematically delaying and denying medically necessary care for seniors enrolled in Medicare Advantage plans. The bill targets what consumer advocates and physicians have described as a growing crisis inside the Medicare Advantage system, where automated algorithms can reject care requests in seconds — sometimes without any licensed clinician ever reviewing the case.

Prior authorization is the process by which Medicare Advantage insurers require your doctor to get advance approval before you can receive certain treatments, procedures, specialist visits, or post-acute care like skilled nursing or home health services. In Original Medicare (Parts A and B), prior authorization requirements are far more limited. But Medicare Advantage plans — the private insurance alternative to Original Medicare that covers roughly 33 million beneficiaries as of 2025 — are permitted to impose their own prior authorization rules, as long as they ultimately cover everything Original Medicare covers. The problem, according to a 2022 report from the Department of Health and Human Services Office of Inspector General, is that Medicare Advantage plans denied 13% of prior authorization requests that would have met Original Medicare coverage criteria. In other words, care that should have been covered was being blocked.

What's changed more recently is the speed and scale at which these denials happen. Several major Medicare Advantage insurers, including UnitedHealthcare, have deployed AI and algorithmic tools to process prior authorization requests at volume. A 2023 investigation found that one widely used AI model — called nH Predict, developed by NaviHealth — was flagging patients for discharge from post-acute care facilities like skilled nursing homes based on statistical predictions rather than individual clinical assessments. Patients were being told their coverage would end on a specific date generated by the algorithm, even when their treating physicians believed continued care was medically necessary. UnitedHealthcare faced multiple lawsuits over this practice, and the company announced in 2024 it would retire the nH Predict tool — but the broader use of AI in prior authorization decisions continues across the industry.

The Landsman-DelBene legislation would require that prior authorization decisions involving Medicare Advantage beneficiaries be made or reviewed by a licensed clinician with relevant medical expertise — not rubber-stamped by an automated system. The bill would also require insurers to disclose when AI is being used in the review process and would strengthen the standards for what constitutes a valid denial. Supporters of the bill, including the American Medical Association and several patient advocacy organizations, argue that current CMS rules don't go far enough to prevent algorithmic overreach. CMS did finalize new prior authorization rules in 2024 that require Medicare Advantage plans to make decisions faster — 72 hours for urgent requests and 7 calendar days for standard requests — but those rules don't restrict the use of AI in making those decisions.

For beneficiaries, the practical impact of AI-driven denials can be severe. Consider a scenario that plays out regularly: a senior recovering from a hip replacement is in a skilled nursing facility. Her physician recommends 20 days of rehabilitation. The Medicare Advantage plan's AI system, based on aggregate data about patients with similar diagnoses, flags her for discharge after 12 days. The plan sends a notice that coverage will end. She and her family must either pay out of pocket — skilled nursing care can cost $300 to $500 per day or more — or file an appeal. Many beneficiaries don't appeal, either because they don't know they can, don't understand the process, or simply don't have the energy to fight while recovering from surgery. The insurer saves money. The patient goes home before she's ready.

If you are in a Medicare Advantage plan and receive a prior authorization denial, you have more rights than many people realize. First, you can request a fast appeal — called an expedited redetermination — if waiting for a standard decision would seriously jeopardize your health. For urgent situations, the plan must respond within 72 hours. For standard appeals, the deadline is 60 days from the denial notice. If the plan upholds its denial, you can escalate to a Qualified Independent Contractor (QIC), then to the Office of Medicare Hearings and Appeals (OMHA), and ultimately to federal court if the dollar amount at stake meets the threshold (currently $180 or more for QIC review, and $1,850 or more for OMHA review in 2025). You can also request a fast appeal directly to an independent review organization if you're facing discharge from a hospital or skilled nursing facility — this is called a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) review, and it can be requested the same day you receive a discharge notice.

The legislative push comes as Medicare Advantage faces broader scrutiny over its financial practices. The Medicare Payment Advisory Commission (MedPAC) has repeatedly flagged that Medicare Advantage plans are paid more per beneficiary than Original Medicare costs for the same population — a gap that reached an estimated $83 billion in overpayments in 2023 according to MedPAC analysis. Critics argue that prior authorization denials, including AI-assisted ones, are one mechanism by which plans manage costs in ways that benefit their bottom line at the expense of patient care. Insurers counter that prior authorization helps prevent unnecessary procedures and keeps premiums lower for all enrollees.

For beneficiaries choosing between Medicare Advantage plans during the Annual Enrollment Period (October 15 through December 7 each year) or the Open Enrollment Period (January 1 through March 31), prior authorization burden is a factor worth researching before you commit. CMS publishes prior authorization data by plan, and Medicare's Plan Finder tool at medicare.gov/plan-compare allows you to compare plans side by side. You can also look up a plan's Star Rating — plans with 4 or 5 stars generally have better track records on appeals and customer service. If you're currently in a plan with a history of aggressive prior authorization denials and you're in generally good health, switching during AEP to a plan with a lower denial rate may reduce friction when you need care most.

The Landsman-DelBene bill does not yet have a Senate companion or a scheduled committee vote, which means it faces a long road to becoming law. But the political pressure it represents — combined with ongoing litigation against insurers and CMS's own tightening of prior authorization rules — signals that the regulatory environment around AI in Medicare Advantage is shifting. Beneficiaries who understand their appeal rights today, and who factor prior authorization practices into their plan selection decisions, are better positioned to protect their access to care regardless of what Congress ultimately does.