Experimental or Investigational Treatment Sample Clauses

Experimental or Investigational Treatment. We do not Cover any health care service, procedure, treatment, or device that is experimental or investigational. However, We will Cover experimental or investigational treatments, including treatment for Your rare disease or patient costs for Your participation in a clinical trial, when Our denial of services is overturned by an External Appeal Agent certified by the State. However, for clinical trials, We will not Cover the costs of any investigational drugs or devices, non-health services required for You to receive the treatment, the costs of managing the research, or costs that would not be Covered under this Contract for non-investigational treatments. See the Utilization Review and External Appeal sections of this Contract for a further explanation of Your Appeal rights.

Experimental or Investigational Treatment. Any experimental or investigational treatment, therapy, procedure, drug or drug usage, facility or facility usage, equipment or equipment usage, device or device usage, or supplies that are not recognized as being in accord with generally accepted professional medical standards or as being safe and effective for use in the treatment of an illness, injury, or condition at issue. Services that require approval by the federal government or any agency thereof, or by any state governmental agency prior to use, and where such approval has not been granted at the time the services were rendered, shall be considered experimental or investigational. Services which are not approved or recognized as being in accord with accepted professional medical standards, but nevertheless are authorized by law or a governmental agency for use in testing, trials, or other studies on human patients, shall be considered experimental or investigational.

Experimental or Investigational Treatment a) Experimental and investigational treatment is covered on a case by case basis. b) Experimental or investigational treatment for life-threatening and/or disabling illnesses may also be considered for coverage under the external appeal process pursuant to the requirements of Section 4910 of the PHL under the following conditions: i) The Enrollee has had coverage of a health care service denied on the basis that such service is experimental and investigational, and ii) The Enrollee's attending physician has certified that the Enrollee has a life-threatening or disabling condition or disease; A) for which standard health services or procedures have been ineffective or would be medically inappropriate, or B) for which there does not exist a more beneficial standard health service or procedure covered by the Contractor, or C) for which there exists a clinical trial, and iii) The Enrollee's provider, who must be a licensed, board-certified or board-eligible physician, qualified to practice in the area of practice appropriate to treat the Enrollee's life-threatening or disabling condition or disease, must have recommended either: A) a health service or procedure that, based on two (2) documents from the available medical and scientific evidence, is likely to be more beneficial to the Enrollee than any covered standard health service or procedure; or