In such cases, independent reviewers should consider such documents as nationally accepted practice guidelines and treatment protocols. The therapeutic criteria developed by health plans should also be evaluated. The reviewer doesn't necessarily have to agree with these standards. But the quality and credibility of the decision is significantly strengthened if the criteria used are based upon applicable, published studies and consensus group statements. Early on, some states passed laws that dealt exclusively with disputes about experimental and investigational therapies.
Most states now have broader laws that also encompass medical necessity disputes.
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.