‘‘(3) MEDICAL PROFESSIONALS MUST REVIEW
INITIAL COVERAGE DECISIONS INVOLVING MEDICAL
APPROPRIATENESS
OR
NECESSITY
OR
INVESTIGA-
TIONAL ITEMS OR EXPERIMENTAL TREATMENT OR
TECHNOLOGY.—If an initial coverage decision under
paragraph (2)(A)(i) or (2)(B)(i) is based on a deter-
mination that provision of a particular item or serv-
ice is excluded from coverage under the terms of the
plan because the provision of such item or service
does not meet the plan’s requirements for medical
appropriateness or necessity or would constitute in-
vestigational items or experimental treatment or
technology, the review under paragraph (2)(A)(ii) or
(2)(B)(ii), to the extent that it relates to medical ap-
propriateness or necessity or to investigational items
or experimental treatment or technology, shall be
conducted by a physician or, if appropriate, another
medical professional, who is selected by the plan and
who did not make the initial denial.
‘‘(4) ELECTIVE EXTERNAL REVIEW BY INDE-
PENDENT MEDICAL EXPERT AND RECONSIDERATION
OF INITIAL REVIEW DECISION.—
‘‘(A) IN GENERAL.—In any case in which
a participant or beneficiary, who has received
an adverse coverage decision which is not re-
versed upon review conducted pursuant to para-
graph (1)(C) (including review under paragraph
(2)(A)(ii) or (2)(B)(ii)) and who has not com-
menced review of the coverage decision under
section 502, makes a request in writing, within
30 days after the date of such review decision,
for reconsideration of such review decision, the
requirements of subparagraphs (B), (C), (D)
and (E) shall apply in the case of such adverse
coverage decision, if the requirements of clause
(i), (ii), or (iii) are met.
‘‘(i) MEDICAL APPROPRIATENESS OR
INVESTIGATIONAL
ITEM
OR
EXPERI-
MENTAL TREATMENT OR TECHNOLOGY.—
The requirements of this clause are met if
such coverage decision is based on a deter-
mination that provision of a particular
item or service that would otherwise be
covered under the terms of the plan is ex-
cluded from coverage under the terms of
the plan because the provision of such item
or service—
‘‘(I) does not meet the plan’s re-
quirements for medical appropriate-
ness or necessity; or
‘‘(II) would constitute an inves-
tigational item or experimental treat-
ment or technology.
‘‘(ii) CATEGORICAL
EXCLUSION
OF
ITEM OR SERVICE REQUIRING EVALUATION
OF
MEDICAL
FACTS
OR
EVIDENCE.—The
requirements of this clause are met if—
‘‘(I) such coverage decision is
based on a determination that a par-
ticular item or service is not covered
under the terms of the plan because
provision of such item or service is
categorically excluded from coverage
under the terms of the plan, and
‘‘(II) an independent contract ex-
pert finds under subparagraph (C), in
advance of any review of the decision
under subparagraph (D), that such
determination primarily requires the
evaluation of medical facts or medical
evidence by a health professional.
‘‘(iii) SPECIFIC EXCLUSION OF ITEM
OR
SERVICE
REQUIRING
EVALUATION
OF
MEDICAL FACTS OR EVIDENCE.—The re-
quirements of this clause are met if—
‘‘(I) such coverage decision is
based on a determination that a par-
ticular item or service is not covered
under the terms of the plan because
provision of such item or service is
specifically excluded from coverage
under the terms of the plan, and
‘‘(II) an independent contract ex-
pert finds under subparagraph (C), in
advance of any review of the decision
under subparagraph (D), that such
determination primarily requires the
evaluation of medical facts or medical
evidence by a health professional.
‘‘(iv) MATTERS
SPECIFICALLY
NOT
SUBJECT TO REVIEW.—The requirements
of subparagraphs (B), (C), (D), and (E)
shall not apply in the case of any adverse
coverage decision if such decision is based
on—
‘‘(I) a determination of eligibility
for benefits,
‘‘(II) the application of explicit
plan limits on the number, cost, or
duration of any benefit, or
‘‘(III) a limitation on the amount
of any benefit payment or a require-
ment to make copayments under the
terms of the plan.
Review under this paragraph shall not be avail-
able for any coverage decision that has pre-
viously undergone review under this paragraph.
‘‘(B) LIMITS
ON
ALLOWABLE
ADVANCE
PAYMENTS.—The review under this paragraph
in connection with an adverse coverage decision
shall be available subject to any requirement of
the plan (unless waived by the plan for financial
or other reasons) for payment in advance to the
plan by the participant or beneficiary seeking
review of an amount not to exceed the greater
of (i) the lesser of $100 or 10 percent of the
cost of the medical care involved in the decision,
or (ii) $25, with such dollar amount subject to
compounded annual adjustments in the same
manner and to the same extent as apply under
section 215(i) of the Social Security Act, except
that, for any calendar year, such amount as so
adjusted shall be deemed, solely for such cal-
endar year, to be equal to such amount rounded
to the nearest $10. No such payment may be
required in the case of any participant or bene-
ficiary whose enrollment under the plan is paid
for, in whole or in part, under a State plan
under title XIX or XXI of the Social Security
Act. Any such advance payment shall be subject
to reimbursement if the recommendation of the
independent medical expert or experts under
subparagraph (D)(iii) is to reverse or modify
the coverage decision.
‘‘(C) REQUEST
TO
INDEPENDENT
CON-
TRACT
EXPERTS
FOR
DETERMINATION
OF
WHETHER
COVERAGE
DECISION
REQUIRED
EVALUATION
OF
MEDICAL
FACTS
OR
EVI-
DENCE.—
‘‘(i) IN GENERAL.—In the case of a
request for review made by a participant or
beneficiary as described in subparagraph
(A), if the requirements of clause (ii) or
(iii) of subparagraph (A) are met (and re-
view is not otherwise precluded under sub-
paragraph (A)(iv)), the terms of the plan
shall provide for a procedure for initial re-
view by an independent contract expert se-
lected by the plan under which the expert
will determine whether the coverage deci-