323 - Inappropriate Denials for Radiation Therapy in Medicare Advantage Plans: An Independent Review Entity and Call for Action

J. Pasetsky¹, L. A. Kachnic², J. B. Yu³, and D. P. Horowitz⁴; ¹Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, ²Columbia University, New York, NY, ³Saint Francis Radiation Oncology, Hartford, CT, ⁴Columbia University Irving Medical Center, New York, NY

Purpose/Objective(s): Medicare Advantage (MA) plans are obligated to cover all services that Traditional Medicare (TM) covers, except hospice care. When some or part of a service is denied by a MA plan, an appeal can be made. If the appeal is denied or partially denied by the plan, the information must be submitted to an Independent Review Entity (IRE). The IRE makes an appeal decision based on Medicare guidelines as to whether the plan should cover, partially cover or rightfully deny coverage. These decisions are considered favorable, partially favorable or unfavorable respectively, an unfavorable appeal decision translates to an appropriate denial of services.

“Reviewing appeals decisions” is a quality metric used by Centers for Medicare & Medicaid Services (CMS) to determine star ratings for MA plans and it measures the percentage of denials with an unfavorable decision by the IRE. 100% unfavorable would result in 5 stars and less than 87% would be 1 star. Our study aimed to assess whether radiation therapy (RT) services were being wrongfully denied more or less than non-RT services, and if RT services are being wrongfully denied more in 2024 than in 2022.

Materials/

Methods: All data from the Appeals Decision Search on the CMS website were extracted, providing data from 2022 through February 2024. Per the Technical Notes of MA Star Ratings, percentages are calculated as: number of unfavorable decisions divided by number of all decisions (favorable, partially favorable and unfavorable). Chi-squared goodness of fit test was used to compare unfavorable decision rates for RT services to unfavorable decision rates for all services.

Results: For all appeal decisions reviewed by the IRE from 2022, 2023 and 2024, the percentage of unfavorable decisions was 95.21%, 94.69% and 96.05% respectively. For appeal decisions just for RT services, the percentage of unfavorable decisions was 84.96%, 81.19% and 75.19% respectively. The difference was statistically significant for all three years with p values <.00001 (Table 1).

Conclusion: The percentage of inappropriate denials in MA plans for RT services has been increasing and RT services are wrongfully denied by MA plans at a statistically significant higher rate than other services. These data contribute to the growing body of literature that MA plans wrongfully deny life-saving cancer treatments that would have been covered under TM. Considering the high rate of inappropriate denials, RT providers should be encouraged to appeal denials on behalf of their patients in MA plans to improve access to medically necessary treatments. Abstract 323 – Table 1

Year	Services	Favorable + Partially Favorable Appeal Decisions	Unfavorable Appeal Decisions	Total Appeal Decisions	Percent Unfavorable	P value
2022	RT	37	209	246	84.96%	<.00001
	All	7,042	143,226	150,268	95.31%
2023	RT	168	725	893	81.19%	<.00001
	All	9,753	174,010	183,763	94.69%
2024	RT	33	100	133	75.19%	<.00001
	All	1,121	27,230	28,351	96.05%