Your Rights to Appeal Sample Clauses

Your Rights to Appeal a Determination that a Service is Experimental or Investigational A. If you have been denied coverage on the basis that the service is an experimental or investigational treatment, you must satisfy the following two (2) criteria: • The service must otherwise be a Covered Service under this Subscriber Contract; and • You must have received a final adverse determination through Fidelis’ internal appeal process and Fidelis must have upheld the denial or you and Fidelis must agree in writing to waive any internal appeal. B. In addition, your attending physician must certify that you have a life-threatening or disabling condition or disease. A “life-threatening condition or disease” is one which, according to the current diagnosis of your attending physician, has a high probability of death. A “disabling condition or disease” is any medically determinable physical or mental impairment that can be expected to result in death, or that has lasted or can be expected to last for a continuous period of not less than twelve (12) months, which renders you unable to engage in any substantial gainful activities. In the case of a child under the age of eighteen, a “disabling condition or disease” is any medically determinable physical or mental impairment of comparable severity. C. Your attending physician must also certify that your life-threatening or disabling condition or disease is one for which standard health services are ineffective or medically inappropriate or one for which there does not exist a more beneficial standard service or procedure covered by the Plan or one for which there exists a clinical trial (as defined by law). D. In addition, your attending physician must have recommended one of the following: • 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 in order to obtain current information as to what documents will be considered acceptable); or • A clinical trial for which you are eligible (only certain clinical trials can be considered). For the 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 life-threatening or disabling condition or disease.