Hello all,
I am not sure this is the correct path to pursue but I figured after 3 denials it might be worth a shot. The State of California Department of Insurance has a claims service bureu where a consumer can request an Independent medical review. I found forms for the patient and forms to be completed by the physician to request a review. One of the criteria listed in the physician's request is that the treatment is considered Experimental/ Investigational and that the doctor believes
1.)The insured has a terminal medical condition, or a life threatening condition, or a serious debilitating condition.
2.) The insured has a condition that qualifies under one or more of the following.
a. Standard therapies have not been effective in improving the insured's condition.
b. Standard therapies would not be medically appropriate for the insured; or
C. There is no more benificial therapy covered by the policy.
I figured I would try this before seeking legal actions which I am sure would be a long and drawn out process since ERISA has now made it a federal process to sue your insurance company.
I am not aware of other states processes but I would think they are similar.
Here is the link to California's Department of insurance Independent Medical Review application.
http://www.insurance.ca.gov/0100-consumers/0020-health-...ed/0020-imr/#whencan
I hope this process is a help to someone and I hope I can get some help this way.
Abbe