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Experimental or investigational
Experimental or investigational means a service, supply, intervention, or drug that the plan has classified as experimental or investigational and therefore, is not covered, even if the service, supply, intervention, or drug is considered medically necessary. The plan will review scientific evidence from well-designed clinical studies found in peer-reviewed medical literature, if available, and information obtained from the treating provider regarding the service, supply, intervention, or drug to determine if it is experimental or investigational. A service, supply, or drug not meeting all of the following criteria is, in the plan’s judgment, investigational:
- If a prescription drug or device, the health intervention must have final approval from the United States Food and Drug Administration (FDA) as being safe and efficacious for general marketing. However, if a prescription drug is prescribed for other than its FDA-approved use(s) and is recognized as “effective” for the use for which it is being prescribed, benefits for that use will not be excluded. To be considered “effective” for other than its FDA-approved use(s), a prescription drug must be so recognized in one of the standard reference compendia or, if not, then in a majority of relevant peer-reviewed medical literature; or by the United States Secretary of Health and Human Services. See the "Limits on prescription drug coverage" section of your certificate of coverage for more information on experimental or investigational drugs.
- The scientific evidence must permit conclusions concerning the effect of the service, supply, intervention, or drug on health outcomes, which include the disease process, injury or illness, length of life, ability to function, and quality of life.
- The service, supply, intervention, or drug must improve net health outcome.
- The scientific evidence must show that the service, supply, intervention, or drug is as beneficial as any established alternatives.
- The improvement must be attainable outside the laboratory or clinical research setting.
- The service, supply, intervention, or drug is provided by a provider that has demonstrated medical proficiency in the provision of the service, supply, or drug. The service, supply, intervention, or drug is recognized by the medical community in the service area in which they are received.
- The service, supply, intervention, or drug is not considered to be experimental or investigational by U.S. standards.
When the plan receives a claim or request for preauthorization that includes all information necessary to make a decision, you will be informed within 20 business days if the service, supply, or drug is considered experimental or investigational. To determine the necessary documentation, call UMP Customer Service at 1-888-849-3681 (TRS: 711). You may be liable for all charges if you receive services that are determined to be experimental or investigational (see the exclusions list for your plan: UMP Classic, UMP CDHP, and UMP Plus). You may have the right to an expedited appeal.