Medicare insurers must now justify coverage denials to doctors

What it does

This bill requires Medicare insurers and drug plans to base prior authorization decisions (denials of coverage) on written clinical criteria developed with input from practicing physicians, make those criteria publicly available, and ensure that all coverage denials are made by licensed physicians in the relevant specialty. It aims to reduce delays in patient care by requiring 60-day notice before new restrictions take effect and mandating transparency about approval/denial rates.

Why we flagged it

The bill's core mechanism is procedural reform of Medicare prior authorization: it mandates physician involvement, clinical evidence standards, public disclosure, and advance notice. It does not eliminate prior authorization but restructures it to prioritize medical judgment over administrative cost-control.

What the text implies

• May increase administrative burden on Medicare Advantage plans and drug plans, potentially raising their costs and affecting premium pricing for beneficiaries.
• Physician-led review requirement may slow some approvals if qualified specialists are unavailable, creating a different type of delay than the bill aims to prevent.
• Transparency of denial rates could expose variation in coverage practices across regions, potentially triggering beneficiary complaints or regulatory scrutiny.
• Requirement for board-certified physician review may reduce reliance on nurse reviewers or algorithms, shifting labor costs within insurance organizations.

Who it affects

Medicare beneficiaries gain clearer, more physician-driven coverage standards and faster access to care by reducing arbitrary delays. Transparency requirements and physician involvement in criteria-setting reduce the risk of coverage denials based on cost-cutting rather than medical necessity. The bill does not eliminate prior authorization but makes it more accountable and evidence-based.

Who stands to gain

• Medicare Advantage plans (HUM, UNH, CI, ANTM)
• Prescription drug plan sponsors
• Healthcare providers and physicians (reduced administrative friction)
• Pharmaceutical companies (easier access to coverage for drugs meeting clinical criteria)

Named in the bill

Medicare Administrative Contractors, Medicare Advantage plans, Prescription drug plans, Centers for Medicare & Medicaid Services (CMS), American Board of Medical Specialties, American Osteopathic Association, HUM (Humana), MDT (Medtronic), RMD (ResMed)

Where it stands

17 cosponsors: 16 Republicans, 1 Democrats.

• Mar 27, 2025 — Introduced · Congress.gov: “Introduced in House”
• Mar 27, 2025 — Referred to House Committee on Energy and Commerce and House Committee on Ways and Means · Congress.gov: “Referred to the Committee on Ways and Means, and in addition to the Committee on Energy and Commerce, for a…”

Dates and quoted wording are Congress.gov's action record; the timeline shows status changes, not every procedural step.

Money around this bill

19 lobbying clients named this bill on 27 disclosure filings across 3 quarters, Dec 2025 to Jun 2026. Those filings disclosed $10,381,279 in lobbying spend. A filing names 17 bills on average, so that figure is what each filing reported, not a share belonging to this bill.

More lobbying clients named this bill than 96% of bills with at least one filing.

Mark Green, the sponsor, reported $29,535 in PAC receipts in the 2026 cycle.

• American Medical Association — $5,643,000 on 2 filings
• Association for Clinical Oncology — $600,000 on 2 filings
• Bluecross Blueshield of Tennessee — $570,000 on 1 filing
• Ascension Health Alliance D/b/a Ascension — $485,000 on 1 filing
• American College of Emergency Physicians — $468,727 on 1 filing

Lobbying Disclosure Act filings through Jul 20, 2026. A filing shows who paid to lobby on a bill it names, not what changed.