H.R. 2433 — Reducing Medically Unnecessary Delays in Care Act of 2025

This section defines 10 terms for purposes of the Act relating to Medicare prior authorization processes administered by Medicare administrative contractors, Medicare Advantage plans under Medicare Part C, and prescription drug plans under Medicare Part D, including "adverse determination" (i.e., a denial, reduction, or termination of coverage for lack of medical necessity), "authorization," "clinical criteria," "final adverse determination," "health care service," "medically necessary health care service," and "preauthorization."

This section requires contracts between the Secretary of Health and Human Services and Medicare administrative contractors, Medicare Advantage organizations, or prescription drug plan sponsors—effective 90 days after enactment—to comply with eight specified requirements for prior authorization medical decisions, as follows: (1) base any restriction, preauthorization, or adverse determination on medical necessity or appropriateness using written clinical criteria; (2) prohibit denial of coverage solely for lack of independently developed evidence-based standards; (3) obtain input from non-employee, board-certified practicing physicians in relevant specialties and service areas before establishing or substantially altering written clinical criteria; (4) apply consistent, evidence-based written clinical criteria that are nationally recognized, reflect community standards, ensure quality and access, allow case-by-case deviations, and are evaluated and updated annually; (5) post current preauthorization requirements and criteria on their websites in detailed, easily understandable language; (6) provide contracted providers at least 60 days' written notice of, and website updates for, any new or amended preauthorization requirement; (7) publish website statistics on preauthorization approvals and denials categorized by physician specialty, medication or diagnostic test/procedure, indication, and denial reason; and (8) ensure all preauthorizations and adverse determinations are made by licensed, board-certified or board-eligible physicians in the same specialty as the treating provider, under the clinical direction of a state-licensed medical director.