CMS Appeals Federal Court Decision on RADV Rule — What MA Plans Should Do Now

CMS has officially appealed the federal court ruling that struck down its 2023 RADV Final Rule, reaffirming the agency’s commitment to defend extrapolation as a central tool in Medicare Advantage oversight.

On Nov. 21, the Department of Justice filed a notice of appeal in Humana Inc. v. Kennedy to the Fifth Circuit Court of Appeals. The lower court had vacated the RADV rule on procedural grounds, finding CMS violated the Administrative Procedure Act by shifting its legal justification without proper public notice. That decision temporarily removed CMS’ authority to extrapolate RADV findings across an entire contract, limiting recovery to the specific overpayments found in sampled charts.

By appealing, the administration is signaling that it views extrapolation as essential for recovering billions in potential MA overpayments and preventing unsupported diagnoses from driving inflated risk scores. The move also highlights CMS’ intent to preserve its ability to apply extrapolation back to PY2018 if the rule is reinstated.

What health plans should be doing now:

• Stay audit-ready — Validate documentation, strengthen chart retrieval, and ensure every submitted diagnosis can withstand medical-record review.

• Accelerate deletion programs — Proactively remove unsupported codes; CMS will continue targeted recoveries regardless of the appeal.

• Model both regulatory scenarios — Prepare financial exposure estimates whether extrapolation returns or the vacatur stands.

• Evaluate provider and vendor coding patterns — Identify outliers and high-risk HCC areas before CMS leverages its own analytics and AI tools.

• Enhance governance and provider education — Reinforce documentation standards and expectations across the network.

• Monitor appeal milestones — A Fifth Circuit reversal could swiftly reinstate extrapolation and reshape audit exposure.

Regulatory uncertainty will continue throughout the appeal, but the direction is clear: CMS is actively defending its RADV strategy. MA plans should strengthen compliance and audit preparedness now rather than waiting for a final ruling.

How Rebellis Can Help

Rebellis partners with Medicare Advantage organizations to build strong, audit-ready operations. Our team supports end-to-end RADV readiness, including documentation review, deletion strategies, HCC coding integrity, provider education, governance structures, and financial exposure modeling. As CMS’ appeal moves forward, we help plans stay compliant, minimize risk, and navigate regulatory shifts with confidence.