Medical policy search that answers which coverage criteria applied on the date — with the policy section and version that say so
The criteria that apply, with the policy section and version that say so.
See one case, screen by screen ↓Software that answers which coverage criteria applied to a service, for a plan type, on a date — from the plan’s medical policies, Medicare’s coverage rules and the state Medicaid manual. Medical Policy Search quotes each criterion with its section and edition, and shows every edition of the policy on one strip.
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A health plan keeps hundreds of medical policies, and each is reissued several times a year. A UM nurse, a physician reviewer, an appeals nurse and a member service representative all ask the same question all day: for this service, this plan type and this date, which criteria applied? The answer sits in a policy portal of PDFs that shows only the current edition, a shared drive of retired editions, the Medicare Coverage Database in another tab and the state Medicaid manual.
So denials quote the edition in force on the day of review, not on the date of service, and commercial criteria get applied to Medicare Advantage members — even though a Medicare Advantage plan may use its own criteria only where Medicare’s are not fully established. Reconstructing what changed between two editions, which is exactly what appeals and provider disputes turn on, is done by hand from PDFs.
Estimated split for one wrong-edition citation — the appeal in front of the nurse and the search for every other decision that cited it — by hand and with the solution.
Six agents find the edition in force on the date, check Medicare's rule and quote each criterion; a physician reviewer decides.
Dolores Whitfield, 68, a Medicare Advantage HMO member on basal insulin, got a continuous glucose monitor on 18 Aug 2026. The claim for $841.20 was denied on 4 Sep. Here is what happens next, screen by screen, in the working solution.
APL-26-04417: Karen Whitfield, her daughter and appointed representative, asks the plan to reconsider claim CLM-26-8836104 from Brightwater Medical Supply — a receiver (E2103) and three months of sensors (A4239). The denial notice says the records do not show meter testing four times a day for 60 days, “as required by medical policy MP-DME-031, section 3.6”. The reconsideration is due 27 Nov.
Margin note on the denial: “Wrong edition. §3.6 took effect 1 Sep 2026 (v9). On 18 Aug 2026, v8 was in force and has no §3.6.”
Renee asks: continuous glucose monitor, Medicare Advantage HMO, 18 Aug 2026. The answer comes back as a policy page: MP-DME-031 v8, in force 1 Jan to 31 Aug 2026, approved by the UM committee on 9 Dec 2025 — five criteria and a supply limit, §3.1 to §3.5 and §3.7, each quoted with section, edition and page, each marked against LCD L33822.
“On 18 Aug 2026, MA HMO members were reviewed against MP-DME-031 v8: 5 criteria and a supply limit, all within Medicare’s rule.”
The question reader turned the words into E2103 and A4239, the plan type and the date of service. The version finder read six editions and picked v8. The Medicare rule checker found LCD L33822 governs. The plan-type comparer found the same criteria for every plan type on that date, and the citation checker matched 6 of 6 quotes to v8 word for word, pages 2–3.
Under the answer runs every edition of MP-DME-031, from v5 in 2023 to the v10 draft, with Medicare’s rule beside it. Renee clicks v9: §3.6, the testing log, appears underlined in green — added in v9, effective 1 Sep 2026, 14 days after the date of service — not in force for this question.
“Beyond Medicare’s rule. LCD L33822 has had no testing-frequency requirement since 18 Jul 2021, and a Medicare Advantage plan may not add one (42 CFR 422.101(b)(6)).”
She moves back to v8. The criteria change in place as tracked changes: §3.6 is struck through in red and folds away. On 18 Aug 2026 the criterion did not exist — and for a Medicare Advantage member it would not apply even later.
“Not in force on 18 Aug 2026 — v9 added it 1 Sep 2026.”
The plan-type comparison lays each criterion across Medicare Advantage HMO and PPO, Medicaid managed care, commercial employer group and individual exchange. Under today’s v9 it shows §3.4(a) narrowed for commercial and exchange to three or more insulin injections a day or a pump — and §3.6 applied to every plan type, Medicare Advantage included.
The full tracked changes: one change, §3.6 inserted by v9, approved by the UM committee on 11 Aug 2026. The edition list shows each edition’s summary and approval, and marks v8 “on the date asked” and v9 “beyond Medicare”.
On the appeal, five steps: read the denial, find the edition in force on 18 Aug 2026, check Medicare’s rule, match the records to v8 §3.1–§3.5, draft the decision. Type 2 diabetes, a prescription and an in-person visit on 2 Jul 2026, insulin glargine 22 units daily — 5 of 5 met, §3.6 not in force. Recommended: overturn, pay $841.20 to Brightwater Medical Supply, with the rationale cited and editable.
“Five steps, about 8 seconds. Nothing is decided by the agents.”
Renee sends the case to Dr. Achterberg with the dated answer and five citations. He sees the edition in force, MP-DME-031 v8, the Medicare rule, LCD L33822, and 5 of 5 criteria met — and signs the overturn. Payment of $841.20 is released, and Renee sends the decision letter to Ms. Whitfield and the supplier.
Since 1 Sep, 41 decisions on Medicare Advantage members cited §3.6: 29 claims with $31,870 denied and 12 prior authorizations. In 9 the service came before 1 Sep, when §3.6 did not exist; 7 are already appealed. Renee sends 40 to re-review and tells the director of medical policy. On 21 Oct the UM committee votes on v10, which limits §3.6 to commercial and exchange plans.
The same question, asked by five people across the plan — what their day looked like, and what it looks like now.
Six agents find the edition in force on the date, check Medicare's rule and quote each criterion; a physician reviewer decides.
Turns a question into service codes, a plan type and the date that decides the edition — date of service for claims, date of request for prior authorization, admission date for inpatient stays.
Finds the edition of the policy in force on the governing date, with its effective dates, its UM committee approval and the editions before and after it.
For Medicare Advantage, finds the NCD, LCD or benefit manual section that governs the service on the date, and flags plan criteria that add a requirement Medicare does not have.
Lays the criteria side by side for Medicare Advantage, Medicaid, commercial and exchange plans on the same date.
Builds the tracked changes between any two editions, word by word, with the committee approval and the evidence cited — and every Monday reads Medicare and state Medicaid coverage changes and lists the policies whose answers would change.
Confirms each quoted criterion matches the source edition word for word, with section and page.
On an appeal, matches the member’s records to the criteria in force, marks each one met, not met or not in force, and drafts the rationale and the letter — every sentence cited.
Decides and signs; the UM committee approves editions. The agents propose; a named person decides.
Anyone on the team can ask which criteria applied for a service, a plan type and a date. It answers from the edition in force, with citations.
Which criteria applied to Dolores Whitfield’s glucose monitor on 18 Aug?
Edition v8 of MP-DME-031, in force 1 Jan to 31 Aug 2026. It has five criteria: diabetes, training, use as labelled, insulin or problematic hypoglycemia, and a visit in the six months before the order. There is no §3.6: the testing log came in v9 on 1 Sep, two weeks after the service.
What changed in MP-DME-031 on 1 Sep 2026?
v9 made two changes. It inserted §3.6, a 60-day log of meter tests four times a day, for every plan type, and it narrowed §3.4(a) for commercial and exchange plans to three or more insulin injections a day or a pump. The committee cited internal utilization data, not published evidence.
Can §3.6 apply to Medicare Advantage members?
No. For Medicare Advantage, glucose monitors follow LCD L33822, which has had no testing-frequency requirement since 18 Jul 2021. A plan may use its own criteria only where Medicare’s are not fully set, and on public evidence (42 CFR 422.101(b)(6)). The v10 draft limits §3.6 to commercial and exchange from 1 Jan 2027.
Find other Medicare Advantage denials that cited §3.6
41 since 1 Sep 2026: 29 claims ($31,870 denied) and 12 prior authorizations. In 9 of them the service came before 1 Sep, when §3.6 did not exist. Seven are already under appeal, including Ms. Whitfield’s.
13 screens from the working solution, on its sample data. Pick one to see it large.
Which date decides the edition, which rules govern each plan type, and who signs are settings, not a project.
| Setting | Default | Choose from |
|---|---|---|
| Claims and payment appeals — the edition in force on | Date of service | Date of service · Date the claim was received |
| Prior authorization — the edition in force on | Date of request | Date of request · Planned date of service |
| Inpatient stays | Admission date | Admission date · Each day of the stay |
| Flag plan criteria beyond Medicare’s rule | On — sent to the director of medical policy | On · Off |
| Medicare contractors followed | DME MAC Jurisdiction B + A/B MAC Jurisdiction 8 | DME MAC Jurisdiction B + A/B MAC Jurisdiction 8 · All DME and A/B MAC jurisdictions |
| Medicare coverage rules synced | Weekly, Mondays 06:00 | Weekly, Mondays 06:00 · Daily, 06:00 |
| Keep editions back to | 10 years | 10 years · 7 years · Forever |
| New editions published by | Priya Venkataraman | Priya Venkataraman · Dr. Hal Mbeki |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample health plan data · “target” = the design goal, measured in the live solution · “estimated” = our estimate (15–25 minutes by hand) · “typical” = published figures (KFF, Medicare Advantage prior authorization determinations in 2024, 2026 — 80.7% of appealed denials overturned; HHS-OIG OEI-09-18-00260, 2022 — 13% of denials met Medicare coverage rules). The Medicare Advantage rule is CMS-4201-F, 42 CFR 422.101(b)(6). People, plans and providers named on this page are fictional — characters and sample data in the working solution.
Software that answers which coverage criteria applied to a service, for a plan type, on a date — from the plan’s medical policies, Medicare’s coverage rules and the state Medicaid manual. Medical Policy Search quotes each criterion with its section and edition, and shows every edition of the policy on one strip.
The question reader works out the governing date by the plan’s date rule — date of service for claims, date of request for prior authorization, admission date for inpatient stays. The version finder then picks the edition in force on that date; it never answers from the current edition when a date is given.
For Medicare Advantage, the Medicare rule checker finds the NCD, LCD or benefit manual section that governs the service on the date, and flags any plan criterion that adds a requirement Medicare does not have, citing 42 CFR 422.101(b)(6). It flags; the director of medical policy decides.
Yes. Move along the strip, or pick any two editions, and the criteria change in place as tracked changes — inserted words underlined in green, removed words struck in red — with the effective date and the UM committee approval in the margin.
Yes. In the working solution, one appeal led to 41 Medicare Advantage decisions that cited the same section since it took effect, each with the reason it does not hold. The appeals nurse sent 40 to re-review and told the director of medical policy.
No. Agents find, quote, compare and draft. A physician reviewer decides and signs overturns and adverse decisions; the UM committee votes on new editions and the director of medical policy publishes them. No agent may deny, approve, edit a policy or send a letter.
Your medical policies and every past edition, Medicare national and local coverage rules, the state Medicaid manual and plan benefit documents. Editions are read from the policy portal when published, Medicare rules are synced weekly and the state manual monthly.
The Agentic Solution Engine builds and deploys it from your requirements — your medical policies and their editions, your date rules and a sample of decided appeals — and it goes live once every quality gate has passed. We will walk you through it on your own policies first.
Every criterion shown met or not met, with the page that proves it.
1-min demoUtilization Management AutomationNo missed 72-hour or 7-day deadline, and the yearly metrics from the same data.
1-min demoAppeals & Grievances ManagementEvery appeal decided on time, with the full file read and what is new marked.
1-min demoWe’ll run Medical Policy Search on your own policies and a sample of your decided appeals.