Charles Baker, VP, Compliance Solutions | Victoria Nadzam, MSN, RN, Sr. Consultant
On January 22, 2025, the Department of Health and Human Services was instructed to pause non-essential public communications and website updates. Though framed as a temporary, precautionary measure, this pause has real-world ripple effects on tools that many health plans rely on, including the CMS Appeals Decision Search tool for Part C and Part D. The search tool has not been updated since January, 20, 2025; unless filtered by date, the lack of updates may go unnoticed—creating a false sense that the data is current.
Understanding the significance of missing updates requires a look at how the CMS Appeals Decision Search tool fits into the appeals process for Medicare Advantage and Part D plans. The tool provides access to summaries of Independent Review Entity (IRE) decisions, which play a central role in guiding plan actions and ensuring compliance:
- After a first-level denial, a plan must conduct a reconsideration using Medicare laws, National Coverage Determinations, and Local Coverage Determinations
- If the denial is upheld, the plan must send the case to the IRE, an external reviewer
Plans can use the Appeals Decision Search tool to examine how the IRE has ruled in similar cases, filtering by item/service, keyword, category, or decision type (favorable, unfavorable, or partially favorable).
Best Practice Tip
Medicare Advantage plans are encouraged to incorporate a review of IRE decisions into their internal appeals review process. In the absence of updated IRE decisions, plans should proactively track and trend their internal appeals, especially overturns, to identify patterns and strengthen first-level decision quality.
By categorizing appeals by service type, analyzing rationale for overturns, and spotting reviewer variability, plans can pinpoint training or policy gaps. These insights help refine denial rationale and improve defensibility before cases reach the IRE. Even without new CMS data, internal trends can drive smarter decisions and support performance on the “Reviewing Appeals Decisions” Star measure.
Why This Matters Now
While the communications pause may be temporary, its operational impact is immediate. Plans may be working from stale data, unaware that newer policies or coverage decisions aren’t reflected. And the lack of transparency in updates creates regulatory risk—especially for services with evolving coverage policies in early 2025.
Federal Momentum Is Returning—But Cautiously
There are signs that internal communications are resuming behind the scenes:
- HPMS memos have resumed and CMS issued new guidance to plans in recent weeks, suggesting internal operations are re-engaging
- The 2026 Final Rule materials are currently under review at the Office of Management and Budget (OMB), a key procedural step before publication in the Federal Register that often signals upcoming regulatory movement
These developments hint that public-facing updates may resume soon. In the interim, plans must navigate with incomplete visibility.
Recommendations for Medicare Advantage Plans
- Continue using the Appeals Decision Search while clearly labeling its current limitations within internal workflows
- Monitor HPMS memos and CMS newsletters closely—they may include updates that haven’t yet made it to public websites
- Stay alert for coverage or operational guidance related to 2026, as OMB review of the Final Rule often precedes important strategic pivots
- Consider supplementing decision research with internal appeal outcome tracking and cross-plan benchmarking
When federal guidance goes quiet, smart plans get proactive. Talk with an ATTAC compliance expert to ensure your appeals and coverage strategy stays aligned—and competitive.
About ATTAC Consulting Group
ATTAC Consulting Group is nationally recognized as an expert in regulatory interpretation, design, and operation of effective compliance programs for Medicare, Medicaid and commercial health plans, PDPs, ACA plans, ACOs, IPAs, medical groups, dental and vision plans.
