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Jaycee Brown

Jaycee Brown

Director of Communications

Coverage for Experimental Treatments

Some patients may need experimental treatments due to their “genetic defects and serious injuries” when nothing else works (Insure.com 2009). Some of these treatments along with the technology needed to perform them may be classified as experimental by insurance companies, depending on their parameters (Bruce).  However, based on their classification of experimental treatments, some people may not receive coverage for certain treatments. Even so, they can overturn the companies’ denials.
Insurance companies may not cover treatments they deem experimental. They may exclude these treatments from their policy because of the lack of proof of their medical necessity, meaning that “the cost of covering them is not justifiable” “for a large group of patients” (“Health Insurance Coverage For Experimental Treatment”). Some insurance companies would cover these procedures when there is evidence and research that shows the treatment’s benefits for the patient’s health and that it works “outside the research setting” (Bruce). Along with that, some companies may cover them if they are approved by entities, such as “a medical association and/or an independent board of physicians” (Bruce). Unfortunately, despite the companies’ definitions of experimental or investigational treatment, “[health] plans often deny such claims without thoroughly vetting the science behind the treatment” (Gianelli & Morris). While they would not cover treatments they deem experimental, people can still receive coverage for routine care from their doctor, while they undergo the experimental procedure, which would usually be offered “free of charge” by the trial sponsor (Gelburd 2017).
When people are denied coverage for experimental treatment, people can contest this denial. They could appeal the claim and argue why they should receive coverage, especially when no other procedure has been successful (Gelburd 2017; “Health Insurance Coverage For Experimental Treatment”). For instance, they need to show the medical necessity of the procedure, showing evidence of its results and benefits on “others with [their] condition” and on themselves, if they were able to afford it or went through the procedure in a clinical trial (“Health Insurance Coverage For Experimental Treatment”). Their doctor could also verify the procedure’s benefits based on other patients that he or she provided it to (Gelburd 2017). Patients could even point to “guidelines recommending the treatment and approvals by the Food and Drug Administration (FDA)” (Gelburd 2017). People could argue that the insurance company’s definition of experimental treatment is vague and/or incomprehensible in order to reverse the denial (“Health Insurance Coverage for Experimental Treatment”; Insure.com 2009). In addition, they could also argue that covering this experimental treatment may be cheaper in the long run than treatments for even worse conditions in the future (“Health Insurance Coverage For Experimental Treatment”).
Some insurance companies are cautious around experimental treatments because they may not work. Though, for people with no other options, they need to show that they not only need experimental treatments, but also show that these procedures work in order to receive coverage.

Works Cited
Bruce, Debra Fulghum. “How does my insurer decide what is an experimental treatment?”
sharecare. Accessed September 20, 2018. https://www.sharecare.com/health/medicare-insurance/insurer-decide-what-is-experimental-treatment.
Gelburd, Robin. “Experimental treatments and clinical trials – how to get accepted into one.”
The Hill, January 3, 2017. https://thehill.com/blogs/pundits-blog/healthcare/312521-experimental-treatments-and-clinical-trials-how-to-get-accepted.
Gianelli & Morris. “Fighting a Health Plan’s ‘Investigational’ Denial of a Medical Claim.”
Gianelli & Morris. Accessed September 20, 2018. https://www.gmlawyers.com/News-Articles/Firm-News/2017/Fighting-a-Health-Plan-s-Investigational-Denial-.aspx.
“Health Insurance Coverage For Experimental Treatment.” HealthInsurance.com. Accessed
September 20, 2018. https://www.healthinsurance.com/Article/FullArticle?a=183465.
Insure.com. “Medical treatments insurers won’t touch.” Insure.com. Last modified March 7,
  1. https://www.insure.com/health-insurance/experimental-medical-treatments.html.

1 Comments

  • This is a very helpful article on how insurance companies treat coverage on experimental treatments and tips and suggestions at getting the proper coverage with this in mind.

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