Oncology Prior Authorization and Denial Guide

Coverage criteria and denial counter-arguments for chemotherapy, immunotherapy, targeted therapy, CAR-T, proton therapy, and PARP inhibitors, grounded in the NCCN Compendium, Aetna Medical Policy for chemotherapy and oncology, UHC CDG Oncology, eviCore oncology criteria, and applicable CMS Local Coverage Determinations for chemotherapy administration. Oncology generates denial rates of 10–15% — driven by off-label drug use, site-of-service disputes, and biomarker testing coverage gaps.

Chemotherapy prior authorization: nearly all commercial payers require PA for systemic chemotherapy, immunotherapy, and targeted therapy. NCCN Category 1 and 2A indications are the baseline coverage standard for most payers; off-label use requires prior authorization and documentation that the indication appears in the NCCN Compendium or a peer-reviewed publication. Aetna, UHC, and Cigna all use the NCCN Compendium as the primary clinical evidence standard. Biomarker testing (next-generation sequencing panels such as FoundationOne CDx, CPT 81455) requires prior authorization from most commercial payers and documentation of the intended use in treatment selection.

CAR-T therapy requires prior authorization from all payers and typically requires submission through a specialty PA pathway. Site-of-care requirements specify hospital-based outpatient infusion for CAR-T. Proton therapy (CPT 77520–77525) requires PA from all payers, and most payers follow ASTRO model policies that limit coverage to specific diagnoses (pediatric tumors, skull base tumors, prostate cancer meeting specific criteria) with documented comparative effectiveness justification for other diagnoses.

• All specialty guides
• Appeal Letter Builder — oncology denial appeals
• Clinical evidence references for medical necessity appeals