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

作者：Youngmin Kwon, Kenji V. Aoki, Shelley A. Jazowski, X Hu, Lindsay M. Sabik, Stacie B. Dusetzina, K. Robin Yabroff, Zhiyuan Zheng · 发表于：JAMA Network Open · 年份：2026 · DOI：10.1001/jamanetworkopen.2026.24772 · 研究领域：Economic and Financial Impacts of Cancer、Healthcare cost, quality, practices、Medication Adherence and Compliance

Importance: Despite the goal of utilization management (UM) to facilitate high-value cancer care, concerns about care denials persist. Evaluating justifications for denied claims can clarify the quality of UM decisions. Objective: To examine second-level appeals for denied anticancer medications in Medicare Part D to assess the quality of UM decisions. Design, Setting, and Participants: This cross-sectional study used a large language model (ChatGPT 5 Mini, OpenAI) to analyze texts of second-level appeals decisions on denied Part D medications, rendered by a Medicare-contracted reviewer. Data were analyzed from March 13, 2025, to May 12, 2026. Main Outcomes and Measures: From decision summaries, the reasons for first-level denials (as cited by Part D plans) and the outcomes of second-level appeals (favorable vs unfavorable) were examined. The reasons for unfavorable reviews (clerical vs nonclerical) were also examined. Results: We included 4952 second-level appeals from 2020 to 2024 by beneficiaries with hematological (n = 1155 [23.3%]), prostate (n = 876 [17.7%]), digestive (n = 650 [13.1%]), breast (n = 613 [12.%]), and lung, bronchus, and respiratory (n = 430 [8.7%]) cancers. Most appeals were for targeted therapy (n = 2889 [58.9%]) or hormonal therapy (n = 959 [19.4%]). The most common reasons for initial denial or appeals were "non-medically acceptable" indications (ie, off-label use; 3410 [68.9%]), formulary exceptions (545 [11.0%]), and failure to meet preapproval cove...