Why MA Plans Denies Chemotherapy / Infusion Therapy
Regimen not first-line per NCCN guidelines
Off-label use without compendia support
Continuation after disease progression not justified
Know Medicare Advantage's Criteria
Medicare Advantage plans must cover all services covered by Original Medicare (CMS NCDs and LCDs) but may require prior auth. Plans use various criteria including InterQual, MCG, and proprietary guidelines.
Key policies to know:
- Must cover all services covered by Original Medicare
- Can require prior authorization not required by Original Medicare
- CMS NCDs and LCDs serve as coverage floor
- Organization determinations must be issued within 14 days (72 hours for expedited)
Building Your Medical Necessity Argument
Cite specific NCCN guideline category and recommendation level
Document prior treatment lines and responses
Reference tumor molecular markers guiding treatment selection
If off-label, cite peer-reviewed evidence or compendia listing
P2P Call Tips for MA Plans
Cite the relevant CMS NCD or LCD -- MA plans cannot deny what Medicare covers
If the service has a CMS NCD, that trumps the MA plan's internal criteria
Reference CMS regulations on MA coverage obligations
Request expedited determination if clinical urgency exists
Guidelines to Reference
- NCCN Clinical Practice Guidelines by cancer type
- CMS Anticancer Chemotherapy NCD
Relevant CPT Codes
Specialty: Oncology
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