About 1 in 5 second-level appeals of denied anticancer medications in Medicare Part D were overturned, according to a study published July 23 in JAMA Network Open. Researchers analyzed 4,952 second-level appeals from 2020 to 2024.
Here are four things to know:
- Overall, 19.5% of appeals received favorable reviews, meaning a Medicare-contracted reviewer overturned the Part D plan’s initial denial.
- The reversal rate was highest for drugs initially denied for failing to meet prior authorization coverage criteria, which generally involved on-label prescribing. Among these appeals, 61.1% received favorable reviews.
- Most appeals involved drugs initially denied for non-medically accepted indications, or off-label use, accounting for 3,410 appeals, or 68.9% of the total. Of these, 16.5% received favorable reviews. Clerical issues were cited in 72.6% of unfavorable reviews in this category.
- The researchers said the findings suggest Part D plans may be making inappropriate utilization management decisions. They pointed to streamlining the preapproval process for on-label therapies as a potential improvement.
