2023 Nevada Revised Statutes › Chapter 695C - Health Maintenance Organizations › NRS 695C.16932 - Required provision concerning coverage for biomarker testing for diagnosis, treatment, management and monitoring of cancer in certain circumstances; establishment of process to request exception or appeal denial of coverage; time for responding to request for prior authorization.

1. Subject to the limitations prescribed by subsection 4, a health maintenance organization that issues a health care plan shall include in the plan coverage for medically necessary biomarker testing for the diagnosis, treatment, appropriate management and ongoing monitoring of cancer when such biomarker testing is supported by medical and scientific evidence. Such evidence includes, without limitation:
(a) The labeled indications for a biomarker test or medication that has been approved or cleared by the United States Food and Drug Administration;
(b) The indicated tests for a drug that has been approved by the United States Food and Drug Administration or the warnings and precautions included on the label of such a drug;
(c) A national coverage determination or local coverage determination, as those terms are defined in 42 C.F.R. § 400.202; or
(d) Nationally recognized clinical practice guidelines or consensus statements.
2. A health maintenance organization shall:
(a) Provide the coverage required by subsection 1 in a manner that limits disruptions in care and the need for multiple specimens.
(b) Establish a clear and readily accessible process for an enrollee or provider of health care to:
(1) Request an exception to a policy excluding coverage for biomarker testing for the diagnosis, treatment, management or ongoing monitoring of cancer; or
(2) Appeal a denial of coverage for such biomarker testing; and
(c) Make the process described in paragraph (b) available on an Internet website maintained by the health maintenance organization.
3. If a health maintenance organization requires an enrollee to obtain prior authorization for a biomarker test described in subsection 1, the health maintenance organization shall respond to a request for such prior authorization:
(a) Within 24 hours after receiving an urgent request; or
(b) Within 72 hours after receiving any other request.
4. The provisions of this section do not require a health maintenance organization to provide coverage of biomarker testing:
(a) For screening purposes;
(b) Conducted by a provider of health care for whom the biomarker testing is not within his or her scope of practice, training and experience;
(c) Conducted by a provider of health care or a facility that does not participate in the network plan of the health maintenance organization; or
(d) That has not been determined to be medically necessary by a provider of health care for whom such a determination is within his or her scope of practice, training and experience.
5. A health care plan subject to the provisions of this chapter that is delivered, issued for delivery or renewed on or after October 1, 2023, has the legal effect of including the coverage required by this section, and any provision of the plan or renewal which is in conflict with the provisions of this section is void.
6. As used in this section:
(a) "Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of a normal biological process, a pathogenic process or a pharmacological response to a specific therapeutic intervention and includes, without limitation:
(1) An interaction between a gene and a drug that is being used by or considered for use by the patient;
(2) A mutation or characteristic of a gene; and
(3) The expression of a protein.
(b) "Biomarker testing" means the analysis of the tissue, blood or other biospecimen of a patient for the presentation of a biomarker and includes, without limitation, single-analyte tests, multiplex panel tests and whole genome, whole exome and whole transcriptome sequencing.
(c) "Consensus statement" means a statement aimed at a specific clinical circumstance that is:
(1) Made for the purpose of optimizing the outcomes of clinical care;
(2) Made by an independent, multidisciplinary panel of experts that has established a policy to avoid conflicts of interest;
(3) Based on scientific evidence; and
(4) Made using a transparent methodology and reporting procedure.
(d) "Medically necessary" means health care services or products that a prudent provider of health care would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and:
(1) Provided in accordance with generally accepted standards of medical practice;
(2) Not primarily provided for the convenience of the patient or provider of health care; and
(3) Significant in guiding and informing the provider of health care in providing the most appropriate course of treatment for the patient in order to prevent, delay or lessen the magnitude of an adverse health outcome.
(e) "Nationally recognized clinical practice guidelines" means evidence-based guidelines establishing standards of care that include, without limitation, recommendations intended to optimize care of patients and are:
(1) Informed by a systemic review of evidence and an assessment of the risks and benefits of alternative options for care; and
(2) Developed using a transparent methodology and reporting procedure by an independent organization or society of medical professionals that has established a policy to avoid conflicts of interest.
(f) "Network plan" means a health care plan offered by a health maintenance organization under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the health maintenance organization. The term does not include an arrangement for the financing of premiums.
(g) "Provider of health care" has the meaning ascribed to it in NRS 629.031.
(Added to NRS by 2023, 2221)