Dallas – In their article, “Strategies for Responding Effectively to a Denial of Treatment as Experimental or Investigational,” Thompson & Knight Trial Partner Jennifer Rudenick Ecklund and Trial Associate Andrew C. Cookingham examine health benefit plans’ language about exclusion for treatment that is considered experimental or investigational and the steps a provider can take to avoid or reverse the denial of benefits. The article is published in the current edition of the Journal of Health & Life Sciences Law.
According to the article, “The plan’s language is often the most crucial factor in determining whether a treatment is properly excluded from coverage as experimental or investigational.” This determination “can have significant consequences for providers, especially in regards to reimbursement” as well as to the patient who is denied a potentially life-saving treatment.
If a denial of benefits occurs, “overturning a plan’s denial of coverage for a treatment because the plan has deemed the treatment experimental or investigational can be a complicated process.” However, the authors outline various factors that enable a provider to “proactively approach the appeal, external review, and litigation or arbitration if necessary, to maximize [the appeal’s] chance for success.”
To read the full article, click here.