Common use of Your Right to Appeal A Determination that A Service is Experimental or Investigational Clause in Contracts

Your Right to Appeal A Determination that A Service is Experimental or Investigational. If We have denied coverage on the basis that the service is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You must satisfy the two (2) requirements for an external appeal in paragraph “A” above and Your attending Physician must certify that Your condition or disease is one for which: 1. Standard health services are ineffective or medically inappropriate; or 2. There does not exist a more beneficial standard service or procedure covered by Us; or 3. There exists a clinical trial or rare disease treatment (as defined by law). In addition, Your attending Physician must have recommended one (1) of the following: 1. A service, procedure or treatment that two (2) documents from available medical and scientific evidence indicate is likely to be more beneficial to You than any standard Covered Service (only certain documents will be considered in support of this recommendation – Your attending Physician should contact the State for current information as to what documents will be considered or acceptable); or 2. A clinical trial for which You are eligible (only certain clinical trials can be considered); or 3. A rare disease treatment for which Your attending Physician certifies that there is no standard treatment that is likely to be more clinically beneficial to You than the requested service, the requested service is likely to benefit You in the treatment of Your rare disease, and such benefit outweighs the risk of the service. In addition, Your attending Physician must certify that Your condition is a rare disease that is currently or was previously subject to a research study by the National Institutes of Health Rare Disease Clinical Research Network or that it affects fewer than 200,000 U.S. residents per year. For purposes of this section, Your attending Physician must be a licensed, board- certified or board eligible Physician qualified to practice in the area appropriate to treat Your condition or disease. In addition, for a rare disease treatment, the attending Physician may not be Your treating Physician.

Your Right to Appeal A Determination that A Service is Experimental or Investigational. If We have denied coverage on the basis that the service is an experimental or investigational treatment (including clinical trials and treatments for rare diseases), You must satisfy the two (2) requirements for an external appeal in paragraph “A” above and Your attending Physician must certify that Your condition or disease is one for which: 1. Standard health services are ineffective or medically inappropriate; or 2. There does not exist a more beneficial standard service or procedure covered by Us; or 3. There exists a clinical trial or rare disease treatment (as defined by law). In addition, Your attending Physician must have recommended one (1) of the following: 1. A service, procedure or treatment that two (2) documents from available medical and scientific evidence indicate is likely to be more beneficial to You than any standard Covered Service (only certain documents will be considered in support of this recommendation – Your attending Physician should contact the State for current information as to what documents will be considered or acceptable); or 2. A clinical trial for which You are eligible (only certain clinical trials can be considered); or 3. A rare disease treatment for which Your attending Physician certifies that there is no standard treatment that is likely to be more clinically beneficial to You than the requested service, the requested service is likely to benefit You in the treatment of Your rare disease, and such benefit outweighs the risk of the service. In addition, Your attending Physician must certify that Your condition is a rare disease that is currently or was previously subject to a research study by the National Institutes of Health Rare Disease Clinical Research Network or that it affects fewer than 200,000 U.S. residents per year. For purposes of this section, Your attending Physician must be a licensed, board- board-certified or board eligible Physician qualified to practice in the area appropriate to treat Your condition or disease. In addition, for a rare disease treatment, the attending Physician may not be Your treating Physician.