What is a utilization guideline (DUT)?
A DUT is a technical criterion, set by the Agência Nacional de Saúde Suplementar (ANS), Brazil's federal regulator of private health plans, that conditions mandatory coverage of a procedure listed in the Rol de Procedimentos e Eventos em Saúde (Rol of Procedures and Health Events), the national list of what plans must cover. If the patient meets the criterion, the health plan (operadora) must cover the procedure; if not, coverage is no longer mandatory under the Rol.
The Rol is set by Normative Resolution (RN) 465/2021, in force since April 1, 2021 [1]. It has two annexes with different roles (art. 3) [1]:
- Annex I: lists the procedures with mandatory coverage, by contracted plan segment (outpatient, hospital with or without obstetrics, reference plan or dental);
- Annex II: contains the DUTs, which set the criteria that secure coverage for some of the procedures in Annex I.
Not every Annex I procedure has a DUT. When it does, the procedure's row in Annex I points to the matching guideline, and the request must show that the patient meets the criterion. The pillar guide Prior authorization shows where this check fits in the authorization workflow.
Where to find the current DUT
The source is the ANS page “Atualização do Rol de Procedimentos” (Rol of Procedures updates), which publishes Annex I, Annex II and the crosswalk between TUSS (Terminologia Unificada da Saúde Suplementar, Brazil's standard procedure code set for private health plans) and the Rol [3]. In October 2026, the file names showed RN 681/2026 as the latest amendment to Annex II [2][3].
Three ways to look it up:
- Annex II as a PDF: the full document, with all 176 numbered guidelines and the appendix of amending rules [2].
- Public Rol search (ROL-web): search by procedure name to check whether it is part of mandatory coverage [3].
- TUSS x Rol crosswalk: a spreadsheet that links the TUSS code on the request to the Rol item and, through it, to the DUT [3].
The Rol is updated continuously. The Annex II appendix lists more than 30 normative resolutions between RN 453/2020 and RN 681/2026, at least five of them from 2026 (RNs 670, 671, 679, 680 and 681) [2]. Law 9,656/1998, as amended by Law 14,307/2022, gives ANS 180 days, extendable by 90, to finish reviewing each proposal to add a technology [5]. A DUT saved on the authorization team's computer goes stale quickly.
A recent example: DUT 52, for digital mammography, often cited as an example of an age-based guideline, was removed from Annex II by RN 679/2026, effective October 1, 2026 [2]. According to ANS, once the guideline was removed, the exam became covered with no age or gender restriction, as long as a physician orders it [10]. The lesson for the hospital is simple: check which version of Annex II applies on the date of the request.
What kinds of criteria does a DUT require?
Each DUT has its own wording, but Annex II criteria fall into a few recurring types. The table shows the type, an example checked in Annex II, and the document that usually proves the criterion in the request [2]:
| Type of criterion | Example in Annex II | Document that proves it |
|---|---|---|
| Patient age or profile | DUT 27 (bariatric surgery): over 18; between 16 and 18 only with a BMI-for-age z-score above +4 and fused growth plates | ID document; bone age report when required |
| Measurable clinical value | DUT 27: BMI 35–39.9 kg/m² with life-threatening comorbidities, 40–49.9 kg/m², or 50 kg/m² or more | Report with measured, dated weight, height and BMI; list of comorbidities with ICD codes |
| Failure of prior treatment | DUTs 16 and 27: clinical treatment failure for at least 2 years | Medical record or report with start date, duration and outcome of clinical treatment |
| Prior test with a defined result | DUT 7 (vacuum-assisted breast biopsy): BI-RADS 4 or 5 lesion; DUT 4 (anti-CCP): negative rheumatoid factor | Report of the prior test, with date and result |
| Minimum time on another therapy | DUT 31 (HIV genotyping): antiretroviral therapy for at least 6 months and viral load above 5,000 copies/ml; DUT 33 (cochlear implant): hearing aid use for at least 3 months, as a rule | Prescription history; viral load test; report from the speech-language pathologist or ENT |
| Exclusion criterion | DUT 27: uncontrolled psychiatric disorder, severe decompensated cardiopulmonary disease, among others | Statement from the attending physician that no exclusion applies, with specialist opinions when relevant |
In the examples in the table, the criteria are objective and can be checked on paper. The health plan does not need to “trust” the indication; it needs to see the number, the date and the report that place the patient within the DUT.
How to build the request so it meets each criterion
A well-documented request answers the DUT item by item, in the guideline's order. The attending physician makes the indication; the authorization team checks that proof of each criterion is attached before it goes out.
- Identify the procedure by its TUSS code and find its row in Annex I. If there is a DUT, record its number and the version of Annex II you checked [2][3].
- Turn the DUT into a checklist. Each criterion becomes a line: what the guideline requires, the document that proves it, and where the data appears in the report.
- Write the medical report in the DUT's language. Diagnosis with ICD code, measured and dated values, prior treatments and their results, and the sentence that ties the case to the guideline (for example, “patient meets DUT 27, group II, BMI of 41.2 kg/m² measured on the exam date”).
- Attach the test reports behind the numbers. A medical report without the test that supports it often comes back as a pending item.
- Log the submission. Keep the date, the protocol number and the DUT version used, so you can follow up on the response and, if a denial comes, answer the stated reason.
RN 465/2021 addresses requests by the attending physician or attending dentist and provides that Rol procedures may be performed by any qualified health professional [1]. A DUT may still set requirements on who performs the procedure: DUT 12 (vasectomy), for example, requires a professional qualified to perform the reversal [2].
For inpatients, DUTs also reach outpatient procedures tied to the continuity of a hospital stay, which hospital plans cover: art. 19, § 2, of RN 465/2021 makes that coverage conditional on meeting the guideline, when there is one [1].
A DUT does not replace deadlines or a reasoned denial
Meeting the DUT does not pause ANS deadlines. A documented request runs within the response deadlines of RN 623/2024 (5 business days, or 10 for high-complexity procedures and elective admissions) and the care deadlines of RN 566/2022 [4]. The guide ANS maximum care timeframes has both tables.
If the health plan denies the request, the denial must be in writing, whether or not it is asked for, with the reason and the contract clause or legal provision that supports it (RN 623/2024, art. 14) [4]. For a DUT denial, that means naming the criterion that was not met. Generic answers do not meet the rule [4]. RN 623/2024 covers members' requests; between hospital and health plan, the contract and RN 503/2022 apply, and RN 503 requires the contract to identify which services need authorization and the response routine [8].
Unmet DUT, technical disagreement or off-Rol request: which case is it?
These are three situations with different paths. Mixing them up delays the response, because each one calls for a different document.
| Situation | What it means | Path described in the rules |
|---|---|---|
| DUT not proven | The procedure is in the Rol and has a DUT, but the request does not show that one or more criteria are met | Add the missing document and resubmit, citing the criterion and the Annex II version |
| Technical disagreement | The attending physician and the health plan disagree on the indication for the procedure or device | Medical or dental board (junta médica, RN 424/2017), within the RN 566/2022 deadlines [9]; see the guide Medical board and technical disagreement |
| Outside the Rol or outside the DUT | The procedure is not in the Rol, or the case does not fit the guideline | Coverage possible only under Law 9,656/1998, art. 10, §§ 12 and 13 (Law 14,454/2022), on the criteria set by the Supreme Court in ADI 7265 [5][6][7] |
Law 14,454/2022 made the Rol the basic reference for coverage and allowed treatment outside it under defined conditions [5]. On September 18, 2025, Brazil's Supremo Tribunal Federal (STF, the Federal Supreme Court) partly upheld ADI 7265 (a direct action of unconstitutionality) and set five cumulative criteria [6][7]:
- a prescription by a qualified physician or dentist;
- no express rejection by ANS and no pending Rol update review;
- no therapeutic alternative in the Rol;
- efficacy and safety proven by evidence-based medicine (high-grade evidence or health technology assessment);
- registration with Anvisa (Agência Nacional de Vigilância Sanitária, Brazil's health products regulator).
The ruling also mentions a prior request to the health plan and consultation of NatJus (Núcleo de Apoio Técnico do Judiciário, the courts' technical support unit) in lawsuits [7]. This guide describes what the law and the ruling say; assessing each case is a legal matter. The guide ANS Rol of Procedures covers off-Rol coverage in more detail.
Mistakes that lead to a DUT denial
The reasons for pending items and denials tend to repeat. Reading Annex II criteria points to a few predictable failure points:
- Outdated DUT version. The request cites a criterion from wording that predates the current Annex II.
- A number without a report. The medical report states BMI, viral load or a test classification, but the source test report is not attached.
- Prior treatment with no duration. The DUT requires a minimum time (2 years, 6 months, 3 months) and the report only says “clinical treatment failed.”
- Exclusion criterion ignored. The DUT lists contraindications and the report does not state that they were assessed.
- Mismatched TUSS code. The requested code does not match the Rol item that carries the DUT, and the review stalls on the crosswalk.
For procedures that use implants and special devices (OPME), the DUT adds to the quote and Anvisa registration requirements. The guide OPME authorization covers that workflow. And if the authorization comes through but the procedure is delayed, check the authorization code's validity in the guide Expired authorization code.
What we see in operations
At Accrua, a request subject to a DUT (utilization guideline) is checked criterion by criterion before it goes out. Accrua OS matches the requested procedure against the current guideline in Annex II and that health plan's authorization rule, and points to the document in the medical record that supports each criterion: a report, a prior test, a clinical score or a record of earlier treatment.
When a criterion has no supporting document, the alert reaches the team before submission, with a note on what is missing. Closing the gap at that point keeps it from reaching the health plan as missing documentation. If the health plan still denies the request, we prepare the supporting documents with the evidence and the relevant rule; deciding the next step belongs to a person.
Because DUTs change often, we follow the resolutions that amend Annex II and update our review rules. What we learn from each denial, reversed or upheld, goes back into the next requests for that procedure and that health plan.
Where to start
- Download the current Annex II from the ANS page and record the date and the RN of that version (currently RN 681/2026).
- List the procedures with a DUT that the hospital requests most, matching TUSS codes against the TUSS x Rol crosswalk.
- Build a checklist for each DUT, with each criterion, the document that proves it and the field of the medical report where it appears.
- Agree on a report template with the medical staff that cites the DUT and includes measured, dated values.
- Review the checklists with every new RN that amends Annex II, and log the change.