West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-97 - External Review of Adverse Health Insurance Determinations › Section 114-97-8 - External Review of Experimental or Investigational Treatment Adverse Determinations

Current through Register Vol. XLI, No. 28, July 12, 2024
8.1. Within four months
				after the date of receipt of a notice of an adverse determination or final adverse
				determination that involves a denial of coverage based on a determination that the
				health care service or treatment recommended or requested is experimental or
				investigational, a covered person may file a request for external review with the
				Commissioner.
8.2. A covered person may
				make an oral request for an expedited external review of the adverse determination
				or final adverse determination pursuant to subsection 8.1 if the covered person's
				treating physician certifies, in writing, that the recommended or requested health
				care service or treatment that is the subject of the request would be significantly
				less effective if not promptly initiated. Such a request shall be handled in
				accordance with the procedure set forth in subsections 7.2 through and including
				7.8.
8.3. Except for a request for
				expedited external review made pursuant to subsection 8.2, the Commissioner shall
				notify the issuer of any request made pursuant subsection 8.1 within one business
				day after the date of receipt of such request.
8.4. Within six business days following receipt of
				a copy of a covered person's external review request from the Commissioner pursuant
				to subsection 8.3, the issuer shall send the Commissioner and the covered person its
				determination whether the request is complete and if it is eligible for external
				review; such determination shall be based on consideration on the following:
8.4.a. The individual is or was a covered person
				in the health benefit plan at the time the health care service or treatment was
				recommended or requested or, in the case of a retrospective review, was a covered
				person in the health benefit plan at the time the health care service or treatment
				was provided;
8.4.b. The recommended or
				requested health care service or treatment that is the subject of the adverse
				determination or final adverse determination:
8.4.b.1. Is a covered benefit under the covered
				person's health benefit plan except for the issuer's determination that the service
				or treatment is experimental or investigational for a particular medical condition;
				and
8.4.b.2. Is not explicitly listed as
				an excluded benefit under the covered person's health benefit plan with the
				issuer;
8.4.c. The covered
				person's treating physician has certified that one of the following situations is
				applicable:
8.4.c.1. Standard health care services
				or treatments have not been effective in improving the condition of the covered
				person;
8.4.c.2. Standard health care
				services or treatments are not medically appropriate for the covered person;
				or
8.4.c.3. There is no available
				standard health care service or treatment covered by the issuer that is more
				beneficial than the recommended or requested health care service or treatment
				described in subdivision 8.4.d;
8.4.d. The covered person's treating physician:
8.4.d.1. Has recommended a health care service or
				treatment that the physician certifies, in writing, is likely to be more beneficial
				to the covered person, in the physician's opinion, than any available standard
				health care services or treatments; or
8.4.d.2. Who is licensed, board certified or board
				eligible physician qualified to practice in the area of medicine appropriate to
				treat the covered person's condition, has certified in writing that scientifically
				valid studies using accepted protocols demonstrate that the health care service or
				treatment requested by the covered person that is the subject of the adverse
				determination or final adverse determination is likely to be more beneficial to the
				covered person than any available standard health care services or
				treatments;
8.4.e. The
				covered person is deemed to have exhausted the issuer's internal grievance process
				as set forth in W.Va. Code of St. R. §114-95; and
8.4.f. The covered person has provided all the
				information and forms required by the Commissioner that are necessary to process an
				external review.