1 in 5 Denied Cancer Drugs Are Approved on Appeal: What Patients Need to Know

Medicare Part D plans are required to cover all or nearly all cancer drugs. That has not stopped them from denying coverage in individual cases. When patients push back, roughly 1 in 5 of those denials are reversed by an outside reviewer according to a study published in JAMA Network Open. The study was led by Youngmin Kwon, a postdoctoral research fellow in the Department of Health Policy at Vanderbilt University Medical Center. In the video, Kwon walks through what happens after a denial and why the numbers concern him.

The appeals process has layers. A patient or their care team can first ask the plan to reconsider. If that fails, the case moves to a second level, where an independent review entity contracted by Medicare (not the insurance plan) decides whether the original denial was correct.

"If we think that Part D plans internally do a really great job of approving what is necessary, then ideally we should see the overturning rate of zero," Kwon said.

The difference between on-label and off-label prescriptions is what Kwon called most concerning. Denials involving drugs used according to their FDA-approved indication were overturned far more often than denials involving off-label use, suggesting some treatments that fit the label were rejected anyway.

Kwon also described something patients rarely hear about: many appeals fail for paperwork reasons rather than medical ones. A missing lab result or an uncited study can cost weeks of delay. He noted that the burden of assembling that documentation falls largely on oncologists and their staff. Shifting that responsibility away from patients and providers is where he sees room for policy change.

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