AI algorithms used to determine eligibility for US government healthcare coverage are increasingly verboten, the federal agency Centers for Medicare & Medicaid Services (CMS) told health insurance companies in a memo this week.
The 14-page memo touches on a wide variety of issues related to the Department of Health and Human Services subsidiary's Medicare Advantage rules published in April last year.
Passages in the memo about algorithms being used to make healthcare decisions, however, seem tailor-made to address controversy over the use of such software in denying Medicare Advantage coverage, which has led to multiple lawsuits. Medicare Advantage is a privately run alternative to the US federal government's standard Medicare offerings.
"An algorithm that determines coverage based on a larger data set instead of the individual patient's medical history, the physician's recommendations, or clinical notes would not be compliant [with Medicare rules enacted in April]," CMS said in the memo. The rule affects Medicare coverage from the start of 2024.