Many health insurers decline coverage for experimental medical treatments simply because there is not enough evidence of success to warrant deeming them medically necessary. Because these treatments and medications cannot be established as effective for a large group of patients, the cost of covering them is not justifiable. Yet for many patients, these investigative treatments and cutting-edge medications represent real hope for improved health. If you have been denied coverage by your health insurer, request a written statement of exactly why your desired treatment has been rejected. This will give you a starting point for working with your company and your doctors to get coverage for the treatment you seek.
When seeking experimental or investigative treatment, you are your own best advocate. The first step is to establish that the treatment is indeed medically necessary in your particular case. To do this, gather evidence to support positive outcomes resulting from the procedure or medication. It is important to collect scientific or anecdotal support explaining that the treatment has been effective for others with your condition. However, it is more important to establish that you have personally exhausted all other options. If you can show that traditional treatments or medications have not worked for you or have ceased working, this can go a long way to convincing your health insurance carrier to consider alternatives. Furthermore, if you have been able to pay for your desired experimental treatment out of pocket or have participated in a clinical trial and have had positive results, showing documented proof of this can lend further credence to your case. Educate yourself in the terms and language of your health insurance policy. Read your policy carefully to determine how your insurer defines experimental treatment. If the terms of your policy are vague, this ambiguity can work in your favor. Your particular therapy may not be categorized as experimental, even if your claim has been denied. If your health plan includes coverage for prescription medications, find out if your state has laws regulating off-label uses of approved drugs. In many states, health insurance providers who offer prescription drug coverage are required to pay for any and all uses of the medications included in their plans, even if the treatments are non-traditional and as long as those uses can be proven to be effective or are supported by the scientific literature.
As a last resort, plead your case in terms of economic common sense. Would it be more cost efficient for your insurer to pay for experimental treatment or a traditional course of therapy? Could the investigational treatment be cheaper than not treating your condition at all? Will the experimental treatment prevent a more serious, and potentially more expensive, condition from developing? Work with your primary-care physician or specialist to determine the answers to these questions and take them to your insurer for consideration.
When you want experimental or investigational treatment for a medical condition, it is important to educate yourself, advocate for your health and work with trusted healthcare providers to help you get the coverage you need.
Healthinsurance.com LLC is a commercial site designed for the solicitation of insurance from selected health insurance carriers. It is not an insurer, an insurance agency, or a medical provider. You may obtain a complete list of available Medicare plans by contacting 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
This site is not maintained by or affiliated with the federal government’s Health Insurance Marketplace website or any state government health insurance marketplace.