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5.15.2024 Use of AI for UM Decisions May organizations use artificial intelligence to make medical necessity denial decisions or appeal decisions?

No. NCQA UM standards do not allow the use of AI to make medical necessity denial decisions, or any appeal decisions. 

If an organization uses AI in the UM process, medical necessity review requires that denial decisions be made only by an appropriate clinical professional and appeal decisions require same-or-similar specialist review, as specified in the NCQA standards.  

ALL 2024