Question
Are there policy exclusions other than experimental or investigational denials that qualify for external review?
Yes Answer
Incorrect!
If the insurer denies your claim based on a policy exclusion, the insurer must tell you which provision is the basis for the denial. Typically, you cannot use external review to get coverage for a treatment that is excluded under the policy. But be aware of some special rules:
- If the exclusion is for investigational or experimental treatment, you still qualify for external review.
- If the exclusion is for cosmetic procedures, but your doctor’s position is that this treatment is medically necessary, then there is a disagreement about whether the exclusion applies, and you still qualify for external review.
- If you have an individual or small group policy, federal law gives you the right to ask your insurer to cover a drug that does not appear on the insurer’s formulary. Check your policy’s appeals section for details.
No Answer
Correct!
If the insurer denies your claim based on a policy exclusion, the insurer must tell you which provision is the basis for the denial. Typically, you cannot use external review to get coverage for a treatment that is excluded under the policy. But be aware of some special rules:
- If the exclusion is for investigational or experimental treatment, you still qualify for external review.
- If the exclusion is for cosmetic procedures, but your doctor’s position is that this treatment is medically necessary, then there is a disagreement about whether the exclusion applies, and you still qualify for external review.
- If you have an individual or small group policy, federal law gives you the right to ask your insurer to cover a drug that does not appear on the insurer’s formulary. Check your policy’s appeals section for details.
