RS 22:1144 Appeal and external review of experimental or investigational determinations
§1144. Appeal and external review of experimental or investigational determinations
A. All appeals pursuant to this Section shall be subject to the provisions of R.S. 22:1122 et seq., and shall be conducted by a medical necessity review organization licensed or authorized pursuant to this Subpart or a certified independent review organization.
B. In order to be eligible for the second level internal appeal or external review process described in this Subpart, an item or health care service deemed to be experimental or investigational in an adverse determination shall meet all of the following criteria:
(1) The allowable charge designated by the health insurance issuer shall be greater than five hundred dollars.
(2)(a) An item or health care service shall be approved by the federal Food and Drug Administration (FDA), if subject to FDA approval; however, absence of FDA approval for off label use shall not preclude eligibility.
(b) If not subject to approval by the federal Food and Drug Administration (FDA), support of use of the item or health care service by medical or scientific evidence.
C. At any time during the appeal process, an MNRO may, at its option, send the item or proposed health care service to the standard external review process described in R.S. 22:1133.
D. During its review of a proposed item or health care service, a medical necessity review organization or an independent review organization shall make its decision or recommendation as follows:
(1) It shall ensure that the criteria described in Subsection B of this Section are met.
(2)(a) Except for an opinion provided pursuant to R.S. 22:1135, each reviewer's opinion shall be in writing and include the following information:
(i) A description of the covered person's medical condition.
(ii) A description of the indicators relevant to determining whether there is sufficient evidence to demonstrate that the recommended or requested item or health care service or treatment is more likely than not to be beneficial to the covered person than any available standard item or health care services or treatments and the adverse risks of the recommended or requested item or health care service or treatment would not be substantially increased over those of available standard items or health care services or treatments.
(iii) A description and analysis of any medical or scientific evidence considered in reaching the opinion.
(iv) A description and analysis of any evidence-based standard.
(v) Information on whether the reviewer's rationale for the opinion is based on Subparagraph (E)(5)(a) or (b) of this Section.
(b)(i) For an expedited external review, each clinical reviewer shall provide an opinion orally or in writing to the covered person, the medical necessity review organization and the covered person's health care provider as expeditiously as the covered person's medical condition or circumstances requires, but in no event more than five calendar days.
(ii) If the opinion provided pursuant to Subparagraph (a) of this Paragraph was not in writing, within forty-eight hours following the date the opinion was provided, the clinical reviewer shall provide written confirmation of the opinion to the assigned independent review organization and include the information required under Paragraph (2) of this Subsection.
E. In addition to the documents and information provided pursuant to Paragraph (D)(2) of this Section, to the extent the information or documents are available and the reviewer considers appropriate, the reviewer shall consider the following in reaching an opinion pursuant to Subsection D of this Section:
(1) The covered person's pertinent medical records.
(2) The attending physician or health care professional's recommendation.
(3) Consulting reports from appropriate health care professionals and other documents submitted by the health insurance issuer, covered person, the covered person's authorized representative, or the covered person's treating physician or health care professional.
(4) The terms of coverage under the covered person's health benefit plan with the health insurance issuer to ensure that, but for the determination by the health insurance issuer that the item or health care service is experimental or investigational, such item or health care service would be a covered service under the covered person's health benefit plan.
(5) Whether one of the following items has occurred:
(a) The recommended or requested item or health care service or treatment has been approved by the federal Food and Drug Administration, if applicable, for the condition.
(b) Medical or scientific evidence or evidence-based standards demonstrate that the expected benefits of the recommended or requested item or health care service or treatment is more likely than not to be beneficial to the covered person than any available standard item or health care service or treatment and the adverse risks of the recommended or requested item or health care service or treatment would not be substantially increased over those of available standard items or health care services or treatments.
F. An MNRO may establish a procedure that requires that a health care provider pay the cost of an appeal of a determination that an item or health care service is experimental or investigational when all of the following occur:
(1) The health care provider has made the appeal on behalf of a covered person.
(2) The result of the appeal is that the MNRO's previous adverse determination is upheld.
(3) The MNRO's records indicate a consistent practice by the health care provider of requesting appeals in an extremely high percentage of cases that were not warranted by available medical information.
(4) The commissioner approves the MNRO's action to require payment by the health care provider.
Acts 2008, No. 443, §1, eff. Jan. 1, 2009.
NOTE: Former R.S. 22:1144 redesignated as R.S. 22:1558 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.