42 CFR § 422.137 - Medicare Advantage Utilization Management Committee.
(a) General. An MA organization that uses utilization management (UM) policies and procedures, including prior authorization (PA), must establish a UM committee that is led by a plan's medical director (described in § 422.562(a)(4)).
(b) Limit on use of UM policies and procedures. An MA plan may not use any UM policies and procedures for basic or supplemental benefits on or after January 1, 2024 unless those policies and procedures have been reviewed and approved by the UM committee.
(c) Utilization Management Committee Composition. The UM committee must—
(1) Include a majority of members who are practicing physicians.
(2) Include at least one practicing physician who is independent and free of conflict relative to the MA organization and MA plan.
(3) Include at least one practicing physician who is an expert regarding care of elderly or disabled individuals.
(4) Include members representing various clinical specialties (for example, primary care, behavioral health) to ensure that a wide range conditions are adequately considered in the development of the MA plan's utilization management policies.
(d) Utilization Management Committee Responsibilities. The UM committee must—
(1) At least annually, review the policies and procedures for all utilization management, including prior authorization, used by the MA plan. Such review must consider:
(i) The services to which the utilization management applies;
(ii) Coverage decisions and guidelines for Traditional Medicare, including NCDs, LCDs, and laws; and
(iii) Relevant current clinical guidelines.
(2) Approve only utilization management policies and procedures that:
(i) Use or impose coverage criteria that comply with the requirements and standards at § 422.101(b);
(ii) For prior authorization policies, comply with requirements and standards at § 422.138;
(iii) Comply with the standards in § 422.202(b)(1); and
(iv) Apply and rely on medical necessity criteria that comply with § 422.101(c)(1).
(3) Revise the utilization management policies and procedures as necessary to comply with the standards in this regulation, including removing requirements for UM for services and items that no longer warrant UM.
(4) Clearly articulate and document processes to determine that the requirements under paragraphs (c)(1) through (4) of this section have been met, including the determination by an objective party of whether disclosed financial interests are conflicts of interest and the management of any recusals due to such conflicts.
(5) Document in writing the reason for its decisions regarding the development of UM policies and make this documentation available to CMS upon request.