CALIFORNIA - Pacificare Health Systems

PART A
Experimental or Investigational Treatment
116
Overseeing Your Health Care
A PacifiCare Medical Director may deny a treatment
if he or she determines it is Experimental or
Investigational, except as described in “Cancer Clinical
Trials” under Section 5. Your Medical Benefits. If
you have a Terminal Illness as defined below, you may
request that PacifiCare hold a conference within 30
calendar days of receiving your request to review the
denial. For purposes of this paragraph, Terminal Illness
means an incurable or irreversible condition that has
a high probability of causing death within one year or
less. The conference will be held within five (5) days
if the treating Physician determines, in consultation
with the PacifiCare Medical Director and based on
professionally recognized standards of practice, that
the effectiveness of the proposed treatment or services
would be materially reduced if not provided at the
earliest possible date.
Independent Medical Review
IF YOU BELIEVE THAT A HEALTH CARE
SERVICE INCLUDED IN YOUR COVERAGE
HAS BEEN IMPROPERLY DENIED, MODIFIED
OR DELAYED BY PACIFICARE OR ONE OF ITS
PARTICIPATING PROVIDERS, YOU MAY REQUEST
AN INDEPENDENT MEDICAL REVIEW (IMR)
OF THE DECISION. IMR IS AVAILABLE FOR
DENIALS, DELAYS OR MODIFICATIONS OF
HEALTH CARE SERVICES REQUESTED BY YOU OR
YOUR PROVIDER BASED ON A FINDING THAT
THE REQUESTED SERVICE IS EXPERIMENTAL
OR INVESTIGATIONAL OR IS NOT MEDICALLY
NECESSARY. YOUR CASE ALSO MUST MEET
THE STATUTORY ELIGIBILITY CRITERIA AND
PROCEDURAL REQUIREMENTS DISCUSSED
BELOW. IF YOUR COMPLAINT OR APPEAL
PERTAINS TO A DISPUTED HEALTH CARE SERVICE
SUBJECT TO INDEPENDENT MEDICAL REVIEW (AS
DISCUSSED BELOW), YOU SHOULD FILE YOUR
COMPLAINT OR APPEAL WITHIN 180 DAYS OF
RECEIVING A DENIAL NOTICE.
Eligibility for Independent Medical Review
Experimental or Investigational Treatment
Decisions
If you suffer from a Life-Threatening or Seriously
Debilitating condition, you may have the opportunity
to seek IMR of PacifiCare’s coverage decision regarding
Experimental or Investigational therapies under
California’s Independent Medical Review System
pursuant to Health and Safety Code Section 1370.4.
Life-Threatening means either or both of the following:
a. diseases or conditions where the likelihood of
death is high unless the course of the disease is
interrupted;
b. diseases or conditions with potentially fatal
outcomes where the end-point of clinical
intervention is survival. Seriously Debilitating
means diseases or conditions that cause major
irreversible morbidity.
To be eligible for IMR of Experimental or
Investigational treatment, your case must meet all of
the following criteria:
1. Your Physician certifies that you have a Life-
Threatening or Seriously Debilitating condition
for which:
n
n
n
Standard therapies have not been effective in
improving your condition; or
Standard therapies would not be medically
appropriate for you; or
There is no more beneficial standard therapy
covered by PacifiCare than the proposed
Experimental or Investigational therapy
proposed by your Physician under the
following paragraph.
2. Either (a) your PacifiCare Participating Physician
has recommended a treatment, drug, device,
procedure or other therapy that he or she certifies
in writing is likely to be more beneficial to you
than any available standard therapies, and he
or she has included a statement of the evidence
relied upon by the Physician in certifying his or
her recommendation; or (b) you or your Non-
Contracting Physician – who is a licensed, boardcertified
or board-eligible Physician qualified to
practice in the specialty appropriate to treating
your condition – has requested a therapy that,
based on two documents of medical and scientific
evidence identified in California Health and Safety
Code Section 1370.4(d), is likely to be more
beneficial than any available standard therapy. To
satisfy this requirement, the Physician certification
must include a statement detailing the evidence
relied upon by the Physician in certifying his or
her recommendation. (Please note that PacifiCare