How Do Health Insurers Decide If Treatment is Experimental or Investigative?

May 6, 2024

Medical Treatment Is Ever-Changing

If you watch the daily news, you know that advances in medical treatments for a broad range of illnesses occur regularly. Researchers across the country and around the world work diligently to identify cures for diseases and treatments to alleviate the devastating effects many who are affected suffer. Each discovery is met with joy as it provides hope for those who are ill and their families.

Perhaps nothing is as disappointing as having a health insurance company deny your claim stating the treatment is either experimental or investigative.

Those who receive these notifications may be paralyzed with fear. Their physicians finally identified a treatment that could help, and now the insurance company will not approve payment. Because the price of medical treatment is often astronomical, self-pay for most is simply not an option.

Experimental and Investigative Medical Treatment

Unfortunately, many people in pursuit of relief from serious illness see their insurance companies deny treatment, stating that it is either experimental or investigative.  Experimental treatments are researched to assure their safety, clarify their effectiveness, and determine their benefits. This research often takes the form of clinical trials designed to . . .

• Identify the impact on certain illnesses
• Measure safety and effectiveness
• Conduct risk v. benefit analyses
• Confirm ideal dosage levels.

Investigation treatment, on the other hand, is determined by your specific carrier. The criteria for this determination would be outlined in each policy’s documentation.

Many who are sick exhaust their options in search of approved treatments. Sometimes, nothing seems to work. At this point, they turn to experimental and investigational treatments in hopes of procuring help.  Some of the issues reviewed by insurance companies when determining whether to approve payment for experimental and investigative treatment include regulatory approvals, medical evidence and guidelines, cost of treatment and insurance policies.,

Regulatory Approvals

For a treatment or medication to be considered non-experimental or investigational, it must be approved by the U.S. Food and Drug Administration. Treatments with this designation would be recognized by generally accepted medical standards and understood to be both effective and safe for use.

If your insurance carrier has denied your claim on the basis that it is experimental, and the FDA has approved the treatment, you should consider appealing the decision. An Oklahoma insurance claims denial attorney can help review your situation and assist with this process.

Medical Evidence and Guidelines

The amount of information regarding experimental treatments is considerable. Medical researchers constantly publish updates on their work. While this documentation can be incredibly valuable, in some cases insurance companies can use it to support their decisions not to cover treatment they consider experimental or investigational.

That said, if there is significant or more recent medical research supporting the effectiveness and safety of treatment, it can be presented in an insurance appeal. You want to ensure you provide copies of all studies to the insurance company with your appeal letter so they have proof of the said treatment’s working.

Cost of Treatment

Insurance companies are businesses whose primary goals are to protect their best interests by maximizing profits and minimizing expenses. Unfortunately, the greatest threat to profitability is excessive expenses, like paid claims.

When a medical treatment is new, and costly, your insurance company may categorize it as experimental as a reason for denial.

Appealing decisions like this can be overwhelming, particularly for those who are ill.  As such, many accept these denials as final.  Insurance companies know this, and thus they are incentivized to categorize costly treatments as experimental, even if they have proven to be effective and are widely accepted around the world.

Insurance Company Policies

Many of us don’t take the time to read our health insurance policies from beginning to end. If we did, we would likely see language that excludes coverage for experimental or investigational treatment. It’s commonplace. This language protects these organizations from paying for costly treatments that may not be safe or effective.  However, if you, as the patient, have no other options and your physician is confident that this is the best course of action for you, and evidence exists as to its success, you can appeal their decisions.

Getting Help for Insurance Claim Denials for Experimental or Investigative Treatment

Contact Doug Terry Law Today

Medicine, in general, is experimental. Every day new treatments are identified in hopes of alleviating symptoms and curing disease. Unfortunately, the cost of these can be exorbitant, and insurance companies deny claims coverage regularly.

If you have received a denial letter for treatment you need; don’t lose hope.  Processes are in place to appeal insurance decisions that are unfair or in bad faith. While the road to appeals is complex, help is available. The team at Doug Terry Law is well-versed in successfully addressing claim denials. Their outstanding reputation is well-known throughout the state.

Reach out today at 405-463-6362 to schedule a free consultation. During this meeting, Mr. Terry and his team can review your situation and share how they believe they can assist you in moving forward. When your health is at risk, time is of the essence.  Don’t hesitate. Doug Terry Law is available to begin work for you immediately.