California, for example, requires coverage of procedures still deemed experimental if independent reviewers conclude the care is likely to be of greater benefit than any standard procedure. This standard doesn't mean everything proposed should be approved, no matter how slim the chance of benefit. Such factors as quality of life and the known safety and efficacy of the standard treatment vs. the emerging therapy must be weighed. Even this broader approach does not represent a carte blanche license for all such disputed treatments to be approved, however. Most state laws require independent reviewers to honor the contract terms contained in a health benefit plan.
Employers are understandably unwilling to pay for unproven experimental therapies.
If health insurers were required to pay for every experimental therapy, there would be little incentive for medical device manufacturers, pharmaceutical companies and other developers to adequately evaluate therapies. This is an unfortunate trend, since it raises a number of potential problems, including conflicts of interest. For example, Mississippi and North Carolina require reviews by state-licensed physicians. Especially in less populous states, there may be a limited number of highly specialized experts in some disciplines. The practitioners in a given state are also likely to know each other, so it may be difficult for a physician to distance himself or herself.