Experimental items and medications have limited coverage. We do not delegate utilization management for experimental or investigational services or clinical trials.
Members with cancer may have coverage for routine costs related to the cancer clinical trial. It depends on the state. You should consider recommending the clinical trial if there is a potential for the member to benefit.
Experimental and investigational procedures, items and medications are not a covered MA benefit. Call us at 1-877-842-3210 or 1-888-478-4760 (Individual Exchanges) for a clinical coverage review.
Certain clinical trials are a benefit of MA plans. You should bill Medicare directly. Members can get additional information on clinical trials by calling 1-800-MEDICARE.
After a clinical review, we send a determination notice to the member and health care provider. An experimental/investigational denial requires a disclosure of additional rights. It also requires information regarding the independent external review process. This includes:
Evaluations, tests, and consultations are benefits of both the commercial and MA plans. Coverage for these does not change if the member does not qualify for a clinical trial. For capitated health care providers, the member’s health care provider is responsible for these tests, unless stated differently in your contract.
You can find more information on clinical trials and experimental procedures in: