Reference for experimental/investigational

[Guest Damien]

Does anyone out there know of a good reference, preferably online, for determinations of experimental/investigational treatment? This is a constant issue in our office, and we really need a reliable, up-to-date source for this type of information. Any ideas?

[Dave Baker]

I dunno, but you'll find this interesting:

Challenging Long Term Disability and Health Benefit Denials Under ERISA, by attorney Edward G. Connette, published by the Health Administration Responsibility Project

Excerpt: "This paper will discuss procedures for challenging Long Term Disability ('LTD') and health benefits coverage denials under ERISA ... the majority of reported decisions arise from cases challenging health benefits denials for procedures or drugs deemed 'experimental,' 'investigative' or 'not medically necessary' ... the most commonly litigated issue today is coverage for various HDC/PSCR treatment protocols for breast, ovarian and brain cancer patients."

Link:

http://www.benefitslink.com/links/20000727...27-006369.shtml

[jeanine]

Are you looking for a source that lists these types of things out or are you looking for a good definition? Here is some general guidance. First, if you don't already have at least one physician employed as the medical director who makes these types of decisions, get one. The medical director should be the head of your utilization management team. Here are some of our guidelines that are stated in our booklets: Experimental means services, supplies, care, and treatment which does not constitute accepted medical practice and/or are inconsistent with relevant clinical guidelines or government oversight agency guidelines at the time services are rendered. Drugs must be approved for marketing by USDA; we don't cover anything which is the subject of ongoing phase I or II clinical trials (some phase III excluded) or treatment that requires further studies for maximum dose, efficacy. We rely on our physicians and UM nurses to keep current with peer-accepted medical standards of care. The best I can tell you is to keep abreast of changing medical/government guidelines hopefully through your physicians.

[Guest Damien]

Thanks for the feedback. I was specifically looking for a source for updated lists of what the powers-that-be have determined is or is not experimental/investigational. My dream would be a searchable website that would tell you whether such-and-such a drug, treatment, or device is considered exp./inv. Any tips would be much appreciated.