We understand the frustration and hope that comes with seeking experimental treatments, especially when facing serious health challenges. These situations are extremely difficult and we take our responsibility to review these matters with the utmost respect and seriousness.

While we will not discuss any specific case given privacy laws, we wanted to provide some facts and context around health care coverage for experimental treatments.

1. What experimental treatment is. Experimental treatment refers to a medical intervention that is still in the testing phase and has not yet been fully proven to be safe and effective through extensive clinical trials. These treatments are often part of ongoing research studies aimed at discovering new ways to treat medical conditions. While they hold potential, they may not have enough established evidence to guarantee their success or safety.
    
2. Experimental treatments are generally not covered by insurance. In the United States, experimental treatments are generally not covered by a health benefit that is provided through an employer or government programs like Medicare and Medicaid.  Similar policies exist in other countries like the United Kingdom and Canada. The main reason that experimental treatments are not a covered benefit is because the safety, effectiveness or potential harm of the treatment has not been established.
    
3. Determinations and appeals. Insurance companies determine if a procedure is an “experimental treatment” under a health benefit by examining various factors, including medical policies, FDA approvals, evidence-based clinical guidelines, and peer-reviewed publications. However, if any patient or their doctor disagrees with our determination, they can appeal it to an independent third party. This appeal process allows the patient or their doctor to provide additional information in support of their request. If an expedited appeal is requested, it can occur within 72 hours.
    
4. A patient can decide to proceed with an experimental treatment even if it is not covered by insurance. Insurance companies do not have the ability to approve procedures that are not covered by a patient’s health benefit, such as experimental treatments. If a patient still wants to pursue an experimental treatment after a final coverage decision, they can work with a practicing physician to access the treatment.