Experimental and Investigational Denials by Health Insurers

The Issue: What procedures and supplies are truly experimental or investigational should ordinarily not be a close question. There is evidence-based use of a procedure, and there is FDA clearance of supplies and devices. But, healthcare insurers deny reimbursements based on their own non-medical definitions of experimental and investigational, relying on statements in nonpublic bulletins they create, and on decisions by their paid medical directors.

Our solution: We analyze what is actually experimental and investigational and what is not based on the medical literature. We then seek to have the determinations appealed, mediated, arbitrated, negotiated and, if necessary, litigated.