Second-Level Appeals of Denied Anticancer Medication Claims in Medicare Part D

What is the rationale behind denials of anticancer medications in Medicare Part D, and what factors drive successful appeals? In this cross-sectional study of 4952 second-level appeals for denied anticancer medications submitted to a Medicare-contracted reviewer, 1 in 5 denials were reversed, with a higher rate of successful appeals for on-label indications. A considerable number of successful second-level appeals suggests potentially inappropriate utilization management decisions by Part D plans.

Corresponding Author: Youngmin Kwon, PhD, Department of Health Policy, Vanderbilt University Medical Center, 2525 West End Ave, Ste 12000, Nashville, TN 37203 (youngmin.kwon@vumc.org).

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