| No sole reliance on AI | AI predictions cannot be sole basis for denying, reducing, or limiting services |
| Individual circumstances | Coverage decisions must rely on individual patient history and circumstances, not population-level algorithms alone |
| No alteration of public criteria | AI tools may not alter publicly available coverage criteria |
| Clinician final say | Licensed clinicians must have final decision authority in utilization management |
| Tool vetting | MA plans must vet and validate AI tools used in UM; required audit under February 2024 CMS guidance |
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