Investigative. As determined by us, a drug, device or medical treatment or procedure is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness, or positive effect on health outcomes. We will consider the following categories of reliable evidence, none of which shall be determinative by itself: • There is final approval from the appropriate government regulatory agency, if required. This includes whether a drug or device can be lawfully marketed for its proposed use by the United States Food and Drug Administration (FDA); and • The drug or device or medical, behavioral health or dental treatment or procedure is not the subject or ongoing Phase I, II or III clinical trials; and • Whether there are consensus opinions or recommendations in relevant scientific and medical literature, peer-reviewed journals, or reports of clinical trial committees and other technology assessment bodies. This includes consideration of whether a drug is included in any authoritative compendia as identified by the Medicare program for use in the determination of a medically necessary accepted indication of drugs and biologicals used off-label, as appropriate for its proposed use; and • Whether there are consensus opinions of national and local health care providers in the applicable specialty as determined by a sampling of providers, including whether there are protocols used by the treating facility or another facility studying the same drug, device, medical treatment or procedure. Medically Necessary Care. This is health care services appropriate, in terms of type, frequency, level, setting and duration, to the enrollee’s diagnosis or condition, and diagnostic testing and preventive services. Medically necessary care must be consistent with generally accepted practice parameters as determined by health care providers in the same or similar general specialty as typically manages the condition, procedure, or treatment at issue, and must: • help restore or maintain your health; or • prevent deterioration of your condition The fact that an authorized network, or non-network, provider prescribes treatment does not necessarily mean the treatment is covered under this Contract.
Investigative. As determined by HealthPartners, a drug, device or dental treatment or procedure is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes. The following categories of reliable evidence will be considered, none of which shall be determinative by itself:
Investigative. 22.2.1 The interview of an employee concerning action(s) or inaction(s) which, if proved, could reasonably lead to a suspension without pay, demotion or discharge for that employee, shall be conducted under the following conditions and procedures.
Investigative. As determined by HealthPartners, a drug, device or dental treatment or procedure is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes. The following categories of reliable evidence will be considered, none of which shall be determinative by itself: • Whether there is final approval from the appropriate government regulatory agency, if required. This includes whether a drug or device can be lawfully marketed for its proposed use by the United States Food and Drug Administration (FDA); if the drug or device or dental treatment or procedure is the subject of ongoing Phase I, II or III clinical trials; or if the drug, device or dental treatment or procedure is under study or if further studies are needed to determine its maximum tolerated dose, toxicity, safety or efficacy as compared to standard means of treatment or diagnosis; and • Whether there are consensus opinions or recommendations in relevant scientific, medical and/or dental literature, peer- reviewed journals, or reports of clinical trial committees and other technology assessment bodies. This includes consideration of whether a drug is included in the American Hospital Formulary Service as appropriate for its proposed use; and • Whether there are consensus opinions of national and local health care providers in the applicable specialty as determined by a sampling of providers, including whether there are protocols used by the treating facility or another facility studying the same drug, device, dental treatment or procedure.
