Are Medicare Advantage Plans Unfairly Denying Radiotherapy?

TOPLINE:

Medicare Advantage plans are inappropriately denying radiation therapy services significantly more frequently than other health services, new data show.

METHODOLOGY:

• Medicare Advantage plans are expected to cover all services that Traditional Medicare covers (outside of hospice care). Radiotherapy services for cancer are included in Medicare Advantage plan coverage.
• In the current study, researchers aimed to assess whether radiotherapy services are being inappropriately denied more or less often than other medical services.
• The researchers extracted data that contained appeal decisions from the Centers for Medicare & Medicaid Services website between 2022 through June 2024, focusing on decisions by an Independent Review Entity, which determines the appropriateness of a denial based on Medicare guidelines.
• The analysis involved 1576 radiation therapy appeals and 433,788 total health service appeals. An unfavorable appeal decision indicated that the Independent Review Entity determined the service had been appropriately denied by the Medicare Advantage plan, whereas a favorable appeal decision suggested that the service should have been covered and was inappropriately denied by the Medicare Advantage plan.
• Researchers assessed decisions for trends across treatment modalities and diagnoses, including brachytherapy, stereotactic body radiation therapy, proton therapy, and Intensity-Modulated Radiation Therapy (IMRT).

TAKEAWAY:

• Over the study period, 274 of 1576 (17.4%) radiotherapy appeals were inappropriately denied by Medicare Advantage plans compared with 20,195 of 433,788 (4.7%) appeals for all health services.
• Inappropriate denial rates varied across treatment modalities. The highest rates were for IMRT at 41.1%, followed by stereotactic body radiation therapy (26.1%), proton therapy (13.0%), and brachytherapy (12.8%).
• However, inappropriate denial rates also varied by cancer type. For instance, the rate of inappropriate denials for breast cancer IMRT, specifically, was quite high, at about 82.1%, whereas the rate for proton therapy to treat prostate cancer was quite low, at about 3.5%.
• The rates of unfavorable appeal decisions (ie, appropriately denied services) were significantly lower for radiotherapy than for all health services across all 3 years: 85.0% vs 95.3% in 2022, 81.3% vs 91.7% in 2023, and 84.0% vs 96.6% in 2024.

IN PRACTICE:

“Our data show that patients with MA [Medicare Advantage] plans have significantly higher levels of inappropriate denials [for radiotherapy services] when compared with other health services, with inappropriate denial rates more than three times higher for RT [radiation therapy] services,” the authors wrote. The results “highlight the need for urgent policy changes to prevent Medicare-eligible patients from being inappropriately denied access to cancer treatments.”

SOURCE:

The study, led by Jared Pasetsky, MD, Columbia University Irving Medical Center in New York City, was published online in International Journal of Radiation Oncology, Biology, Physics.

LIMITATIONS:

The data only included cases that reached an appeal after an initial denial and because only about 11% of initial denials are appealed, the study potentially underestimated the total number of inappropriate denials.

DISCLOSURES:

The study did not receive any funding support. Several authors reported receiving travel fees or grants and having other ties with various sources. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.