Oncology News Central (ONC)Oncology Reimbursement Undergoes “Significant Overhaul”: 9 Critical Changes to Know

A UCSF Health Affairs study found 46% of appealed genetic testing denials were reversed, with California reaching 60% overturn rates. Of cancer-related claims, 84% were for treatment, with ovarian cancer denials overturned at 54.8% and non-small cell lung cancer at 44.3%.

⚖️ Professional Impact

• Algorithmic denial for delay is the working theory among oncologists, with one radiation oncologist reporting 100% of his appeals overturned across a 30-40% denial rate
• Delayed genetic testing means delayed precision therapy selection and missed germline risk assessment for family members, with IMR resolution taking weeks to months
• Less than 1% of denials are appealed through independent medical review, suggesting most inappropriate denials go unchallenged and patients go without covered care
• 46 states provide no public IMR data, leaving oncologists without visibility into payer denial patterns or accountability mechanisms

🎯 Action Items

• Document thorough medical necessity justification at the time of every genetic test order
• Cite specific clinical guidelines and peer-reviewed evidence in all prior authorization submissions
• Appeal every denial through independent medical review when clinical guidelines support the claim
• Track denial and overturn patterns by payer to identify systematic obstruction in your practice

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