Inappropriate Appeal Denials for Head and Neck Cancer Surgery in Medicare Advantage Plans

Abstract

Medicare Advantage (MA) plans use prior authorization to manage utilization, with denied services appealable through a five‐level process. Independent review entities (IREs) adjudicate second‐level appeals, determining whether initial plan denials were appropriate. This study assessed whether MA plan denials for head and neck cancer surgery are overturned by IREs at higher rates than denials for other services. We analyzed IRE determinations from January 2020 to December 2024, categorizing appeals as head and neck cancer surgery, surgical oncology, all surgery, or all healthcare services. Among 94 head and neck cancer surgery appeals, 11 denials (11.7%) were favorable/partially favorable. This rate was similar to surgical oncology (9.3%; P  = .45) but significantly higher than all surgical services (5.6%; P  < .001) and all healthcare services (4.5%; P  < .001). The most common denial rationale was inadequate documentation. MA plan denials for head and neck oncologic surgery are overturned by IREs at higher rates compared to general healthcare services, which may represent a barrier to time‐sensitive cancer care.