Medical Exceptions & Appeals: Hidden Approval Path...

Medical Exceptions & Appeals: Hidden Approval Pathways That Accelerate Patient Access

Just because a medication is non-formulary or heavily restricted does not mean access is lost. It often means the right approval strategy has not yet been used. Medical exceptions remain among the most underutilized yet powerful tools for market and patient access. When used correctly, they can secure coverage for non-covered or restricted therapies before an appeal becomes necessary. Most professionals know medical exceptions exist. Few know how to build a compelling request that gets approved. If you are a Field Reimbursement Manager, reimbursement specialist, or prior authorization professional, this workshop delivers practical, real-world strategies to improve approvals, reduce delays, and help patients access therapy faster. In this session, Ned Woody, Executive Associate Director, Quality and Value-Based Care Initiatives at Daiichi Sankyo Oncology, breaks down how medical exceptions work across payer types and why “covered” rarely means unrestricted. You will learn how utilization management differs across Medicare, Medicaid, and commercial plans, the three-part framework for building stronger exception requests, and how appeals become the next critical pathway when exceptions are denied. Attendees of this course will receive both an ACMA Accredited Certificate of Completion and IACET credit.

Participants will learn advanced tactics:

Identifying when medical exceptions significantly improve approval success
Having a clear framework for when an “appeal vs. exception” is the optimal path
How to build stronger medical necessity arguments for difficult cases
Reduce avoidable denials and shorten approval timelines
Understanding Payer Variations: Medicare, Medicaid, Commercial Plans